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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Appfiration for Disposal *pstem Construrtion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon A ❑Complete System ❑Individual Components
Location Address or Lot No. 3 �"T$ox) 5 Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel 3Q(p .r V t4Y4NooS -4vA� M.41Z6�� �( l'f'Y�X)AJI
Installer's Name,Address,and Tel.No.5'62_q7 7_E$f 77 Designer's Name,Address,and Tel.No.
tqA
Type of Building:
Dwelling No.of Bedrooms Lot Size (o,�S 3' 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)
/RAV onl SeP r< SYSW
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date r 10 l 3
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �' Date Issued
r1 i r
No. 20 Ire Fee }
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
1
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01p cation for bisposal 6pstem Construction 3pPrmit
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑Complete System ❑Individual Components
Location Address or Lot No. 5 3 5TE'T`S 01i 5-r Owner's Name,Address,and Tel.No. t
! Assessor's Map/Parcel 30 0 N�'4N0 jS re-1 Ei.S HY411 x11 {,
Installer's Name,Address,and Tel.No. 9102-47 7-9$ 77 Designer's Name,Address,and Tel.No.
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Type of Building:
-,,,.,-,,Dwelling No.of Bedrooms Lot Size (6 55 3{ sq.ft. Garbage Grinder
- Other Type of Building No.of Persons Showers( ) Cafeteria( )
t Other Fixtures
4 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:
r 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'S`of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign-ccL Date
Application Approved by ,A 7 Dates
Application Disapproved by Date
F , for the following reasons
Permit No. (� ) Z Date Issued .
v
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
�ltier. Certificate of Compliance
THIS IS.TO CERTIFY,that the On-site Sewage ,is
Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned o()by �tQLZ. 1(7� `EN CIC!'&5jS -Ld-
at.?3 57C-T50m s 1 hly/d1Um(S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2A13- dated GJ /
Installer CAP1FW(-pE U�J tatAKKESI L.,C Designer , IV
#bedrooms „e� Approved design iqw and
The issuance of this p it hall not be construed as a guarantee that the systernwillwotion as des geed.
Date ! Inspector VVJ
---- --
No. 2 �!(� Fee {
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstrm Construction J)Prmit j
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon X)
System located at 33 sT k*EF r
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:ConstruFt njmust be completed within three years of the date of this pe i it.
Date f // /// 7 Approved by
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ment fell ►,Safety,
and CuviroillUenlnl Scri ices.
Public Health Div.isioll :: Dale
J(17 Main Sirccl,I lynntils MA 02601
nAnNBTAnLF
�°rto rnr.� Date Scheduled j rime ° Pee i tl.
Soil Sciitabilify Assessin.elf. for Selvage .Dishnsal
1'erformcd I)y: A) _M&Qin-q� wiU►cssed 133. DA,/(0 �. I7Ytl�t�45 OfA_
OGA'I.1ON' &QtNtRALi•1NIP.01 1A`I0N
\' L,ocnllon Aildress. 3 5 r Ownersnmc W' N /� . .MC W i I h amS
N }s✓•�•H vfz-c.el1� �i��u�n i S ,.
Address ILA:MVs;ic�
Assessor'sMnp/I'mccL, i') p 3040-r;, 5-5 - I:nginecr'sMime 5i-epiwA 1g
NEW CONSTRUCTION ✓ I r!`Alit 'I•cicphonc It 5 _ I&Z m6t:
' Lnnd use A 6-3-I. Suifncc shies ' Hot4c- o/��{b,c-0.
Dlstnnces from: Open Wntcrpody I 1 11 Possible Wct Arcn �1 17d. n Drinking Wmer Well II
Drnihnge Wny It. 11roperly Lhic 2`? It Other
SICE CH: (Stree(nntiic,dimensions of Iol,exact locntions of lest holes R perc tests,locale wctlnnds in Inoximity to holes)
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1_\jF ALLe-+a - T -1 ►-� F 4.4Ivi U4-e
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k:e-MA L— _ TEST�► I .
u N T-S 2l0'
F.��.�E—r 1-/ GcmI R —r
I'nrenl Innterin)(geologic) �?6.=� Depth to Bedrock 4�5�
Depth to Grottndwnler.'SlmndIng fter in Ilol.e: t./A_ Weeping from I'll irnee �yA
fstlmnleJ$ensonnl I ligh Groundwnter 3.3 Qe2 G t S p DOTO Ta
tits oil
-A Y1r1:l.ft" rriCi; fti>:.rri'a> r5ht i'f:`t.tiP`,i.r' �XIA"i t Y),.t A i!r r
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Method Used: e tS M h 1 s L octj3 Cr- 29 t.' WE rr AIwO p QL A, I o00 v��sT cF sly c=3.3
Depth observed standing Iri obs.hole, . +�/A III, Depth io soil inolllcs:
Depth to wceping frotii side of obs,hole: H/A In. Ground.wnler Ad•luslmcnt +.•l.A. _It;
w-.f- Index.Well N N/A Rending Dnle:Win_.•., .Index 1Vcil bevel F, Adl fnctor .tej.Adt.Qrmmdwnlcr I•C1'cl },Iq
Z'GZZCOIJI't( IY [ S.t' 1)glc':a1 .2U 1 'I'lule (1:15 Am
rvntion Obsc A
Iolc N I l'itnc n19 T6P P"e"
Uclilh of perc I[o Time nl G"
Slut 11rc•sonk Timic @ 11 .11 A' Time(9 G')
2g Cnlaa,.l"s I l mIt.r..!(Z`g .
Did Pro-sank I i 13q. f`
�.'D.M-tHJ tlwGtl
. Itnle Min./Inch '
Site Sullnblllly Assessment:,.Site Pnss'ed Sltc Fniicd: Addhionnl Testhig NccJcd(Y/N)
Origii►nl: Public llenith Ulvlsiori Observnlion 11ole Da In.To.13e Completed on 11ncli j
Copy: Anpilcmtt
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,-:..i.�I-..�w..I.
Depth from Soil Horizon S611 Texture. "Boll Color .Sod Other
Surrace(in) (USDA) (Munsell) Molthng (Structure,Slolics,.nouidcreS;
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/n� 4 qM"e+A%A.6 l 4 444.9:t i.. . 1-rw &:..__. Fir.w e -.4o '.5'
lb��.3L'r. /� SIti1[,f eRAiu ,
1'9 coao�SE nab IcsYR 6°/fw F c � +tc s 4A�E'L_
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Ncs . .GOa.aMD �-±R 4' GE )fir " .. .
ME. OUst,,V 'Z`II�N HOLD LOO.: dole ,
17eptlr ftoin Soli., ., on Soil Texture Soll Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,BJ 1.0deres.
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;;'; ; " Cf #S X���'Y' �.%. X�O�C LOB .Bole#:::y; �.`
.
Depth from Soil Horizon ,Soli Tez'i r $oil Color Soll 651
Surface(in,) (USDA).. (Munsell)' Mottling' (Structure Slorics,.t3otddeies,
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15 pih 11om �11 mrizon. Soil Texture Soil Color Soli Other
"` Surface in. (USDA Munsell Moltlin Structure,Stones,Doulderes. .
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Flood insurance Rafe Man:
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. Above 500 year flood tiaund. ,No._ ,:.Yes v .
VJlthin 500'year bound . 1Jo Yes
:. ary . .
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W111111 f 00 year'flood botindary::No T 1.
Yes
pCnth of Na turally Occ ri.g,Pervious lYlaf.rl
. .
Does at.least four feet of naturally occurring pervious niateria(exist in all:areAs observed tlirtiughout the
. area'proposed for the soil absorpt►on system? : 'Y V .
If.not,whit is the:depth of naturally occurring pervious material? "
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I certifytitat'on "15 pm (date)I have passed the soi.levaluator:examination.approved by the..,
. De, r Tent of Environmental Protection and tlia.t file above,analysis Was performed b.y,me consisteri.t with .
the required training;expertise ande'zperletice described tn.310 CMR`15 Ol7
Signature Date I L 20 oti
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tiPostage $• dS�
Certified Fee 1,j
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Retum Receipt Fee O H e
OO (Endorsement Required) ,
Restricted Delivery Fee
O (Endorsement Required)
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E3 Rosanie Joseph & Severe Philogene
539 River Road
Marstons Mills, MA 02648
Certified Mail Provides:
o A mailing receipt
o A unique identifier for your mailpiece
a A record of delivery kept by the Postal Service for two years
important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
o Certified Mail is not available for arty class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
n 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':
a If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at.the post office for postmarking. If a postmark on the Certified Mail
4_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
COMPLETE •N COMPLETE THIS SECTION ON DELIVERY
p Complete items 1;,2;and 3.Also complete A. gnature
item 4 if Restricted 17elivery is desired. ❑ en
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. R iv by(Printed e) C. Date of Delivery
■ Attach this card to the back of the maiipiece, 2 i
or on the front if space permits.
D. Is delivery address d nt from item 1? ❑.Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I
• I
Rosame-Joseph & Severe Philogene Service Type
❑Certified Mail ❑Express Mail
539 River Road ❑Registered ❑Return Receipt for Merchandise
Marstons Mills, MA 02648 ❑Insured Mall ❑C.O.D.
f, Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number- 7 012 1010 0000 2843 213 3
(Transfer from service labeQ �
Ps Form 3811,February 2004 Domestic Return Receipt 102595-o2-M-1540
E UNITED STATES POSTAL SERVICE ^
I First-Class Mail
Postage&Fees Paid
--- USPS
I Permit No.G-10
I
i
• Sender: Please print your name, address, and ZIP+4 in this box •
------------
Town of Barnstable
Public Health Division
200 Main Streety q
Hyannis, MA 02601
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, Town of Barnstable Barn
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. Regulatory Services Department j
,0� Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 0000 2843 2133
March-11, 2013
Rosanie Joseph & Severe Philogene
539 River Road
Marstons Mills, MA 02648
Re: 33 Stetson Street, Hyannis
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
• The septic system located at 33 Stetson Street, Hyannis, MA was last
inspected in 2010.
A permit was issued on July 14, 2010, Permit# 2010-011, for repair due to
hydraulic failure. This work was never completed. The property is now required
to be connected to the Town Sewer.
You are ordered to obtain an abandonment permit for your the septic system at
the Public Health Division and connect the dwelling to the town sewer within
sixty (60) days from the date of this letter.
Failure to comply within the deadline period will result in future enforcement,
action.
PER ORDER OF T . BOARD OF HEALTH
as McKean, S., C O
j Agent of the Board of Health
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Q:\SEPTIC\Leners Septic Inspection Failures or Future Eval\Stewart Creek Connection Ltr\33 Stetson St.Mar 2013,doc
Parcel Detail http://issgl2/intranet/propdata/Parce]Detail.aspx?fD=24212
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Logged In As: Parcel Detail Wednesday, March 6 2013
Parcel Lookup
Parcel Info
Parcel ID 306-055___...__ Developeer PART OF LOT 18
Location33 STETSON STREET Pri Frontage 1125
Sec Road Seem
Frontage{
Village JHYANNIS Fire District.HYANNIS
Town sewer exists at this address No — Road Index 1534
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Asbuilt Septic Scan: Interactive
306055_1 Map
6, nMF
Owner Info
Owner PH, ROSANIE& PHILOGENE, SEVERE ( Co-Owner!
Streets�539 RIVER RD Street2 1
City[MARSTONS MILLS State iMA Zip,62648_ _ Country
Land Info
Acres 10.38 use Multi Hses MDL-01 zoning RB J Nghbd 0107
Topography Level Road jPaved
Utilities s,Septi Public Water,GacI Location Rear Location
Construction Info
Building 1 of 3
Year 1926 m �l Roof Gable/Hip Ext Wood Shingle
Built _1 Struct Wall
Living Roof AC
Area 12173 —� Cover Asph/F GIS/Cmp I Type,None _ w
Int Bed
Style,Coonial Wall Plastered j Rooms 5 Bedrooms � • � ,
mk
Model Residential Int(�Hardwood Bath�3 Full
Floor I Rooms y r
°
Grade jAverage Plus I Type Hot Air Rooms 8 Total Roo_ms _l '
Heat
Stories 2 Stones Fuel Gas Foation I'Ypical
Gross 3453
Area i
Building 2 of 3
Bear;1920 __ I Roof Gable/Hi Ex [Wood Shingle J
Built� —.J Struct��p Walll
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=24212 3/6/2013
SHE Tp��
Town of Barnstable Barnstable
Regulatory Services Department-;, WAm m`CeC j
BARNSTABLE, O D
M AS S. Public Health Division
AlfD MAC A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 0000 2843 2133
March 11, 2013
Rosanie Joseph & Severe Philogene
539 River Road
Marstons Mills, MA 02648
Re: 33 Stetson Street, Hyannis
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 33 Stetson Street, Hyannis, MA was last
inspected in 2010. `
cam' ���f
A permit was issued on July 14, 2010, Permit # 2010-011, for repai is wo
was never completed. The property is now required to be connected to the Town
Sewer.
You are ordered to obtain an abandonment permit for your the septic system at
the Public Health Division and connect the dwelling to the town sewer wit
sixty (60) days from the date . n. o P- iok,--
Failure to comply within the deadline period will result in future enforcement
action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\Stewart Creek Connection Ltr\33 Stetson St.Mai 2013.doc
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CQM.M.ONA'EAr�T11 OF MA,SSACIJUSETTS
r E-xEcuTix,E 0FF1.(;FJ OF ENviltONMENTAL AFFAiRs
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a iVIAP
PARCEL. ;
LOT
TITTLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL..SYSTEM FORM
PART A
CERTIFICATION
Property Address: 0A1 Add
Owner's Name: i! L&j'ji�
Owner's Address: 33_ 5-nF 7-Aa,�/ AWX
..........
-
Date of.Inspection: .2 ?— c ke F
Name of Inspector:(please print) ' �,r i �rJ r st �� -1
Company Name:
MailingAddress:
Telephone Number. U 3 --7-7 p
CO t�
CERTIFICATION STATEMENT
I certify that.I have personally inspected the sewage disposal system at this address and.that the info tion repQBed
below.is true,accurate and complete as of the time of the inspection.The inspection was performed b. ed on
6 co
training and experience in the proper function and maintenance of on site sewage disposal systems. t m a DEPQ1 r—
approved system inspector pursuant too.Section 1.5.340 of Title-5(310 OMR 15.000). The system rn
Conditionally Passes
Needs Further lvaluation by the Local Approving Authority
Fads
Inspector's Siirnattt.re: 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 I.O,OW
b'pd or greater„the inspector and the system owner shall submit the report to the appropriate regional office of the
D.EF'.The original should be sent to the system owner and copies sent to the buyer,if applicable,and.the approving
authority.
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 51rispection Form 6/15/2000 page I
Page 2 of I i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 93
Owner: 1-'i t r0tc. k ,'f1 r G
Bate of Inspection:
Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section.D
A. System Passes:
—fry- 'have not found any information which indicates that any of the failure criteria described in 31.0 CvIR,
15.303 or in 310 CMR 1.5.304 exist Any failure criteria not evaluated arc indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or.
repaired.The systcm,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N ND),in the_for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether meta:(or not)is structurally
unsound,exhibits substantial infiltration or cxfltration 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.
ND explain:
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 p.ipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is.removal
ND explain:
Title 5 I:nspection Form 6/15/2000 2
Page 3 of i t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: _7 3 5 -7"5 6,t)
1'5 /m
Owner: i 61 'V d lids-s .5
Date of Inspection: V—2-7-09
C. Further Evaluation is Required by the Board of[lealth:
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 3.10 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 100 feet of a
surf~ace 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 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 1,00 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 colilbrm
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.
3. tither:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property.Address: - - ` 6:
Owner, 6 s ft 1.^.C{�''�'`f f,+�../w ✓A�K'7"�,
Date of Inspection:
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
-b zl'bischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
flogged SAS or cesspool
t/ Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or
,zesspool
uid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flaw
[required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
tines pumped
1-�y 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..
y portion of a cesspool or privy is within a Zane 1 of a public well.
,portion of a cesspool or privy is within 50 feet of a private water,supply well.
t 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 conform 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.]
(Yes/No)The system fails.I have determined.that one or more of the above failure criteria exist as
described in 310 CM1t 1.5.303,theroforc 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•
You must indicate either"yes"or"no"to each of the;following:
(The following criteria ap ly to large systems in addition to the criteria above)
yes no
_ the system is within 400 f of a surface drinking water supply
the system.is within 0 feet of a tributary to a surface drinking water.supply
the system is l ated.in, nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone IT of a ublie wa r 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
significantthreat under Section E or failed under Section D shall upgrade the system in accordance with 31.0 CMR
15.304.The system owner should contact the appropriate regional office of the Department. -
4
Title 5 Inspection Form 6/1.5/2000
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART B
CHECKLIST
Property Address: 3
Owner' &//
Date of inspection: ,L•7,_ '
Check.if the following have been done.You must indicate"yes"of"no"as to each of the following:
Yes
Pumping;information was provided by the owner,occupant,or Board of Health
Werc any of the system components pumped out in the previous two weeks
Has the system received normal flows in.the previous two week period
e/Have large volumes of water been introduced to the system recently or as part of this inspection
Were as built plans of the system obutined and examined.?(If they were not available note as NIA)
Was the facility or dwelling=,inspected for signs of sewage back up
t.' 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 ffl baes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum .'
t// Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The slre and location of the Soil Absorption System(SAS)on.the site has been determined based on:
Ye
Existing information.For example,a plan at the Board of Health..
Determined.in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 1.5.302(3)(b)]
Title 5 Inspection Form 611.512000 5
Page 6 of I I
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: S3
(honer: 13i7L
Date of Inspection: 4L/
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 C)tiIR 15.203(for example: 110 gpd x#of bedrooms)-
Number of current residents:
Does residence have a garbage grinder(yes or..no):
Is laundry on a separate sewage system(yes or no):01W[if yes separate inspection required)
Laundry system inspected(yes or no):A-69
Seasonal use:(yes or no):_&O
Water meter readings,if available(Last 2 years usage(gpd)):�31� o�?vo 7$-V
Sump pump(yes or.no):
Last date of occupancy:—100
COM:MER.CIAL/I:NDUSTRIAL
Type of establishment:
Design flow(based on 31 U C 15.203): gpd
Basis of design fl (scats/ rsnnslsgft,etc.):
Grease trap Present es no):
Industrial wasteAboldtank,present(yes or no):
Non-sanitary warged to the Title 5 system(yes or no):
Water meter reavailable:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: RI K+ A V*4 C .4 e— RE
'
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:gallons--How was quantity pumped determined?
Reason for pumping:
TYPE. SYSTEM
ptic 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)
_Tight tank. Attach a copy of the DEP approval
-___,Other(describe):
Approximate age of all components,date ins lied(if known.)and.source of information:
Were sewage odors detected when arriving at the site(yes or no):!moo
Title 5 Inspection Form 6/1.5/2000 6
Page 7 of 11.
OFFICIAL INSPECTION FORM:—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ? ?'S 0^/ 4 r
.4 e2''r
Owner: R iJ1 zin, W;w i'hL*,�Y,S
Date of Inspection: -2�--
BUILDING SEWER(locate on site plan)
Depth below grade: 2 !j
Materials of construction: ._.cast iron 4o PVC�zotber(explainn):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK._ (locate on site plan)
Depth below grade: LZ ��----
Material of construction:jet oncrete_metal_fiberglass---polyethylene
ctthcr(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: . '
Sludge depth:
Distance from tap of sludge to bottom of outlet tee or baffler - .3 `1
Scum thickness: /+/ ��
Distance from top of scum to top of outlet tee or baffle:
Distance ftom bottom of scum to bottom of outlet tee or baffle:, _.
How were dimensions determined- A.Ji'^ Pr'r40 0/--. Ali',PvA
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage;etc.):.
GREASE TRAP: ,,,,(locate on site plan)
Depth below grade:_
Material of constructio concre xneial_f _--polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of un to top.ofoutlet tee or baffle:
Distance from bolt of s um 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.):
Title 5 Inspection Dorm 6f1 5/2000 7
Page 8 of I I
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 335r'Y'>San! �
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (tank.must be pumped at time of.inspection)(locatc on site plan)
Depth below grade: _,
Material of construction: concrete metal„,,,.fiberglass___._.polyethylene other(cxplain):
Dimensions: O e
Capacity: I Soo gallons
Design Flow: _ gallons/day
Alarm present(yes or.no):. �?
Alarm level: Alarm.in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present.must be opened)(locate:on site plan)
Depth of liquid level above outlet invert: �—
Comments(note if box is:level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER l —6(locate on site plan)
Pumps in working order.(yes or no): „w
Alarms in working order(yes or no):_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.).
Title 5 Inspection Form 6/15/2000 8
• Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: +
Owner: L2c. �f/fi
)ate of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
ti' 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.):
CESSPOOLS: (cesspool must be pump as part of inspection)(locate on site plan)
Number and configuration:
Depth�-top ofliqui. to inlet
Depth of solids lay
Depth of scum layer.
Dimensions of ces
Materials of cons truetio�:
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 n site plan),.
Materials of constructi
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Title 5 inspection Fort 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART C
SYSTEM"INFORMATION(continued)
Property Address:.
Owner-
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
I
F a .
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: Hill t tfd-;W' .5
Late of Inspection.
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used-to determine the high ground.inter elevation:
_Obtained from system design plans on record-1f checked,date of design plan reviewed:
Observed site(abutting;property/observation hole within 1.50 feet of SAS)
-A,�<'hccked.with local Board of Health-explain:
'hecked with local excavators,installers-(attach documentation)
V Accessed USGS database-explain:
You mast describe how you established the high ground water elevation.:
Title 5 I;nspecti.on.Form 6/15/2000 11
i
COMMONWEALTH OF MASSACHUSETTS
" EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PR. ,
ONE WINTER STREET, BOSTON MA 02108 (617)
TRUDY CORE
WIIJ IAM F.WELD ,q J, Secretary
Governor R
0 __
ARGEO PAUL CELLUCCI , row I9941 7 DAVID B.STRUHS
Lt. Governor ''�/h Commissioner
k"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Q- Q
PART A
_r CERTIFICATION
Property Address: ?J-i S �Q �So� Ste"'- �-�c./o.,,�,w� Address of Owner: Xri�/o. k Ja cc,�c,C S
Date of Inspection: C> -2 j7-•- / (If different) �O
Name of Inspector:. M 4j� '�
Company Name, Address and Telephone Number: YY° L` 6 Z
'RT`f+.�.sZ'1 L Eti�/�a1�-��'.�„:►s�.,�•U�c x a `i,
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_r�F.ails�,`� A
Inspector's Si nature: "(UIJ (,fy'J11,� Date:
Insp g
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are.indicated below.
B] SYSTEM CONDITIONALLY PASSES:
m onents need to be replaced or repaired. The system, upon completion of the replacement or repair,
system co p
One or more sys p
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/95)
i� Printed on Recycled Paper
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33
Owner.'
Date of Inspection: �
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or bre'kout or high static water level observed in the distribution box is due to broken or obstructed
. �It'pipe(s)�or due to a broken, settled or uneven distribution box. The system will ass inspection if(with y p pe approval of the
Board of Health)
1 broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken.or_obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect tF
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 THA
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS 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 within 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 wat(
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than
ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add,�ess: j 3
Owner: —Say
Date of Inspection:
D] SYSTEM FAILS:
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 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.
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 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 large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Property Address: 33 S_ �p
Owner: � . Sa (y^• - 7c(—s
Date of Inspection:
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 at least two weeks and the system has been receiving normal flow rat(
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
kb As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
3,The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
{
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
zs 22 rSo ' -
Property Address: /yu H pus
Owner: s a .- ri
Date of Inspection:
7 �ts
m4 � i �-lye , . . •
SEPTIC TANK:-Ufrj
(locate on site plan)
Depth below grade:-&[:AwflP—
Material of construction: ,concrete _metal _FRP _other(explain)
Dimensions:
Sludge depth: p�
Distance from top of sludge to bottom of outlet tee or baffle:���
Scum thickness: t It
Distance from top of scum to top of outlet tee or baffle: (O It
Distance from bottom of scum to bottom of outlet tee or baffle: IS�I
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to o tlet invert, structur I
integrity, evidence of leakage, etc.) (�,J
GREASE TRAP:
(locate on site p an)
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:
Distance from bottom of scum to bottom 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, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION .
Property Address: ?l'✓ ,e l—� o
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 15�5)0 allons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes
Laundry connected to system (yes or no):—'T� _in-fb
Seasonal use (yes or no):—A)_6
Water meter readings, if available:
Last date of occupancy: r
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_ £allons/day
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 occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING�RECORDS and source of information:.
.2r2A
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: �' �� ,v�_S�Tic �.�hv►�.
Sewage odors detected when arriving at the site: (yes or no) pip
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:-k6
(locate on site plan)
Depth below grade: -
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Gl6Jl��
Comments:
(note if level and istributio ie ual, evidence o1 solids carryover, evident of leakage into J`ut of boxC�etc)
PUMP CHAMBER:A�D
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) ,
' 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: .14
. S�r �dS
Date of Ins ection:
ev
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excav ion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number:
leaching chambers, number: t&Sl;z% 'R�rT�.S► .
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
fomments: (note condition of il, signs of hydraulic f ilure, le el of pon g, ondition of vegetation,etc.)
CESSPOOLS: c
(locate on site p an) S
Number and configuration: 1 QoUN
Depth-top of liquid to inlet invert: �t.�-A
Depth of solids layer: C� ^�—
Depth of scum layer:
Dimensions of cesspool:_( c
Materials of construction:�- N�
Indication of groundwater: Il1c�
inflow (cesspool must be pumped as part of inspection)
mm nts: (note condition o soil, signs of hydraulic failure, levql of p di condition of veget tion et
6
PRIVY:,
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level or ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART C
r — SYSTEM INFORMATION (continued)
Property Address: _
Owner: A . 5 —/ - /
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
S
�Z aS �Z 30
30 t3- ab
ANA- boll
DEPTH TO GROUNDWATER
Depth to groundwater. i�_feet I. —
method of determination or approximation: MRI 110L 101 ►J0 W
I ?a r �r1 ca-T2 wv
(revised 11/03/95) 9
s.`
.Citizen Web Request Page 1 of 1
EsN
.t
Citizen
- - Request .Management
Request ID: 26956 Created: 9/4/2009 11:58:08 AM
4.
Status: Assigned To Staff Assigned To: Desmarais, Donald
Health Office
Anonymous: No Category: Title 5 : Section 353-7
g ry' Sewage
E.C. Date: 11/30/2009
Created By: Crocker, Sharon Citations:
Health Office
Time Worked: 0.75 Response Time: 1.50
Request Location:
33 STETSON STREET
Hyannis, Ma 02601
Parcel Number: Map: 306 Block: 055 Lot: 000
Request:
Caller said the tenants at address are digging into back yard. Caller thought the house
was condemned by us. No evidence of this in records. Caller believes they are trying to fix a
clog in sewer by themselves. Do not know how caller would concluded this.
F
quest Work History:
ered on 9/8/2009 8:07:35 AM — _ ---
Went and saw that someone had indeed dug up the leaching field. Tenant explained that the
owner had contacted BlueWater to get pumped out and a new system installed. Confirmed this
with BlueWater tuesday,morning. No furthur action unless the project does not move foward.
Entered on 9/22/2009 8:00:32 AM
Tom is meeting with the people due to a problem getting a loan from the county. I have not
been informed what-is going on.
http://issgl2/IntemalWRS/WRequestPrintPub.aspx?ID=26956 11/5/2009
11"SENDER COMPLETE1 •MPLETE THIS SECTION ON DELIVERY
■ Completeutems 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired.. , r ❑Agent
■ Print your name and address on the reverse X= <<'!� ��^ ❑Addressee
sot at we can return the card to you. `
� y B; � iv b�, tedN e) C. Dat fDelivery
■ Attach this cans to the back of the mailpiece,.
or on the front if space permits.
D. d's delivery address rent from item`1? Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
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"9
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2. (Tticle ransfer from.
o i i=7006 �0810 0000 3525 3718
(Transfer from.�rvlce la6eQ -x-? ;t::r x i
PS Form 3811,February 2004 Domestic Return Receipt 102595.02-M154�
UNITED STATES PASS t*TAcu QVI25alop—
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•Sender: Please print your name, address, and ZIP+4:i Is box• ""�
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Q 30 � aF
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cc
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Postage $ �A,
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O Restricted Delivery Fee G �'
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Total Postage&Fees f
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"orPO Box--- J✓! A -----1<0.4..
City,State,Z/P+4 ----------''------
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e Au +nlque identifier for your Ailpie& 1
11,A record of delivery kept by the Postal Service for two years
Important Reminders:
m Certified Mail may ONLY be combined with First-Class WHO or Priority Mail®.
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a For an additional fee,a Retum Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
a 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.
a If a postmark on the Certified Mail receipt Is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
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°FIHE t°w Town of Barnstable, -.--
P� yBarnstable
Board of Health
eriea�tty
• RAR,751'A BILE,
r NASS 2.00 Main Street,Hyannis MA 02601 '
i639. �0
AIF0 Mpi a'
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Junichi Sawayanagi
Paul Canniff,D.M.D.
CERTIFIED MAIL#7006 0810 3525 3718
October 14, 2009
Rosanie Joseph and Severe Philogene
539 River Road
Marstons Mills, MA 02648
RE: 33.Stetson Street, Hyannis
Dear Rosanie Joseph and Severe Philogene:
You are requested to appear at the Board of Health meeting to discuss
future remedy options regarding your failed septic system at 33 Stetson Street,
Hyannis.
The Board meeting,is scheduled for November 10, 2009, at the Town Hall,
367 Main Street, Hearing Room, 2nd Floor, Hyannis. The meeting will begin at
4:00 pm.
Sincerely,
Thomas McKean
Q:\Order letters\Sewage Violations\33 Stetson St Hy BOH Nov2009.doc
'` rY + � - TOWN OF BARNSTA LE
LOCATION > -�4 ; �lo SEWAGE # ` Z
e- 7sl �
VILLAGE A/�at'�J41S ASSESSOR'S MAP & LOT-90 i� �� •
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY l� a o L,411
0-4
LEACHING FACILITY:(type) I. °`1�,,,;.j (size)
NO.OF BEDROOMS�7'� PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER_
d
DATE PERMIT ISSUED: `' z
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE
E�OCATION SEWAGE #
C�V�N C ASSESSOR'S MAP & LOT
VILL/�GE__r
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER 1,0-+w%r%A
PERMTTDATE: 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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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativit for lliripnial 19nr1w Tonfitrnrtiun 11tratit
Application is hereby made for a Permit to Construct ( ) or Repair (Lo,)r'�an Individual Sewage Disposal
System at
.........�—�...............� -.%----- .......... ................... .............. h.l!! ` ......................................................
Loc: ion-Ad< s or Lot No.
----------•--•-•----------
- O�+ner --Address
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling— No. of Bedrooms....--... --------------------_..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.
P4 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........................................
Test Pit No. I................minutes per inch Depth of Test Pit..--_---_-..---_- Depth to ground water........................
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-----------•-...--•.....------•-•••----'-----•-------•-"---•-'--......•--'-.....----•'-'--'-.....•'-•'-..................'-'-'-------_......--•-••......--
0 x Description of Soil........................................................................................................................................................................
U .................'-"'-......
w .............................. ---------------------------------------------------------------------------------------------------------------------------------------- ....••----'----�r
U Nature of Repairs or Alterations—Answer when applicable.--ZAs lf�:r/... _1 .-.1�7 d:.�..... !f .....
...V_� ..Z�c.C.
.........L�.-.� .�?.........iv-•------- !� Cl.Ctl. t✓ 4 .d . ..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issue the board of health.
Signed .. ......� ..... .'9
�J
Application Approved By ----- --v---- . .. .. ................ . ... . -- - ................ ..... .. :.... .. �
Dare
Application Disapproved for the following rear ................................. .. . ...............................................
..................................................... . . .............. .............-- . . ...................................... � -----------
... ....
------- -----
re
Permit No. ----- .....................
------ --- Issued ........ .. .Oare ....�...... .
--------------
r !� �~�
� / / ' '
~ Fom
-
THE COMMONWEALTH orMAssAoHussrrs � -~
U����� ��K� ���� 0�����U'�U� '
BOARD �~" HEALTH
^�- " " "
U �� '
TOWN ���� BARNSTABLE
' ` ^ � =k���m��&� ��� ��' ����K ������ ��� �� '
� ~v-n---~--'-- ~ -- '-n- ~ --- -~- ~-`- ~~~�~�~^`- nr-~-~~~~
. . �~
�. Application i, hereby made for a Permit to Construct ( ) o, Repair (~/,/ ao Individual Sewage Disposal
| ' System at: `
<�_z
------'�=�''L�����......L -'��-['�'--'-'-__- .....................
or Lot No.
Lqion
-'------' -'---'-� vr-------'-------'-------- '--------------------------------'---'--------'
' �� el Address
u"*xer ' - AddTe"
PQ
`. Type ofBuilding Size Lot......:�.'_-_-.__-So fee
D��)�g�--�o �� O�droons---.��.__-_---_--Expaux�m Attic ( ) Garbage Grinder ( )
| - Other--Type of Building ......--__ ......... No. n6 persons............................ Showers ( ) -- Cafeteria ( )
� 04 (Jtbe, fixtures
-----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................ .
Septic Tank-Liquid -.--culnnsLength---------------- Width---------------- Diameter_............. '
Disposal Trencb-- No Width_- Length.................... Total leaching area....................sg f t.
Seepage Pit Nu------' Dianncter---- IQ�dh below inlet.................... Total leaching area..................ag 6.
Z Other Distribution box ( ) Dosing tank
~~ Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Teat PiL.------- Depth to ground water............!t
Test Pii.No. 2................minutes per inch Depth of Test Pit--.------ Depth toground
o� ----------.._---_....................................................... _
0ofSoDescription
�'.----.-'--_' -----__-_-.-_'-.-.--------____-..
'
---.'---.�---'''_---'_---.__-_-''--_'----_-----_--_-'-----__'------'_-____-___-.
-.----------__---.--------------'__-- �
� � ~�����//
��o.--Z�..-../l���d.��--..�n�.---�z.--��l±�1��/�±�l.�.---&e!�..��..-_^J.�w�1���-..'-'-._-------_
� Aoccenoccu: �
� The undersigned agrees »o install the ufocedcocribcJ Individual Sewage Disposal System iu accordance with /
the provisions of TITLE 5 of the Srorc Euvin000aeutu) Code--The undersigned further agrees not to place the
system iu operation until u Certificate of Compliance has 6 ofbcubb.
Signed -lr� ' _. ....
Application Approved 'Bv4_ �P/ //�8/�t-� " 1'��l�8.�,----------' -� �!��Z�,�
/ '--\ - ' ~ /o=
Application Disapproved /�r��x _'---�.'-_-------'---_-_--_--'_----'--
--'r.--'----- -'---------------'------ --
4:1
9crnob �Jo� -/ ��� -/�l �l--' byucd --.�' ,1'�[--_-'
. -'r- ---'/ ' '-/ -- - /'
/ /
--_~-_-—-~-~~~-_---___~-._________---_________----__--- ---_-___________�
THE COMMONWEALTH oFmAeaACHussTTs
BOARD OF HEALTH
TOWN OF BARNSTABU E |
x�erti �m�m ��
��~=°~ x^� ~c,ontlatiavw.e
THIS IS XO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ~~~~T
by ..................... -----' ----- ' --------------------------------------------.
has been -installed -' accordance with the provisions of TITLE 5 of The State Environmental Code as described in '//'
the application for Disposal Works Construction Permit Nv d od �~
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'9 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �^�'~~���� --------------------`- ------ losyccu`'r�---
---------------------------------------------------~~-----------~^~-------
�
rHs ooMmomvvsALrH or mAssxc*ussrre �
BOARD OF HEALTH
' �� ���� ���������������~��
^- / ~7 / n �r�°. . ~~. ~_, ,, ., ,~~ , , ,~_ ~~ �_�)
0o-L-��.---'�-'/ / r��'-.=�.�-----'
ov an Individual Sewage Disposal SystemStreet
as shown on the application for Disposal Works Construction- �
-- a�u� -| ------------------
DA7]I--_.. � � I
' ---'--'-'-'----- / / `
' - / / �/
FORM snon0000BSm WARREN.INo'PUBLISHERS . �