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HomeMy WebLinkAbout0718 STRAWBERRY HILL ROAD - Health 718 Strawberry Hill Road, Hyannis f� t h� f4 l i �I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i, 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name �•` information is Centerville , Ma 02632 6/17/2019 required for every I f page. City/Town State Zip Code Date of Inspection ! > Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imngoutforms A. Inspector Information C t �39(P filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Q Company Address Centerville Ma 02632 City/Town State Zip Code 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 'address listed above; the information reported below is true, accurate and complete as of the time of'my inspection; and the inspection was.performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority I 4. ❑ Fails 6/17/2019 Inspector's Signature Date The system inspectors all submit a copy of this inspection report to the Approving Authority Board p 9 � Y ( of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j 718 Strawberry Hill Road u Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. l 1) System Passes: I ® 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 property located at 718 Strawberry Hill Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach 'pit. The system was found to be in proper working condition at.the time of inspection. I i 2) 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.i If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)lis 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): I I ,I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2,of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address I Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): I i I ❑ The system required pumping more than 4 times a year due to broken or obstructed ipipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C i 3) Further Evaluation is Required by the Board of Health: I ❑ 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3I'of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form ,4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 718 Strawberry HIII Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection' C. Inspection Summary (cont.) 'i 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool i, ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow 1. ❑ ® 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. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 failurw-criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] 1 ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. j i I 5) 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 CA. Yes No i i ❑ ❑ 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood i Owner Owner's Name j information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 1 i 6. You must indicate"yes"or"no"for each of the following for all inspections: I Yes No I ® ❑ 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? ❑ Z Has the system received normal flows in the previous two week period? i ❑ ® Have large,volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ElWas the facility or dwelling inspected for signs of sewage back up?I i ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I { t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 0 Does residence have a_garbage grinder? ❑. Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5/2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: original system installed 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be cleaned soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert oil- 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 was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had 2' standing water with a stain line at 3'. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 •t d l � 2 A-� 3 K A2 `37 B2 25- lr3 ` g3 3) AY 3 S 13� 31 i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 718 Strawberry Hill Road V Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments * � 718 Strawberry Hill Road V Property Address Dan Wood Owner Owner's Name information is required for every Centerville Ma 02632 6/17/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. inspection-Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r -- COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED 5Q% - 350 MAIN STREET WE MAR o i 5 2002 & WEST YARMOUTH,MA 508-775-2800 TG•o.%C.:7 G'iVRNSTABLE TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner's Name: MCLEAN,KENNETH,JR. Owner's Address: 718 STRAWBERRY HILL ROAD MAP CENTERVILLE,MA 02632 Pl�� O�6' Date of Inspection FEBRUARY 19,2002 Name of Inspector: (please print) JAMES D.SEARS LOT Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 2 Date: �l 67 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of 1 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 tot he buyer, if applicable,and the approving authority. Notes and Comments f ****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 1_ T Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' CERTIFICATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X i _ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A I _ 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. I 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 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 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 i indicating that the tank is less than 20 years old is available. ND explain: I _ 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 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 removed ND explain: Title 5 Inspection Form 6/15/2000 2 L Page 3 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 C. Further Evaluation is Required by the Board of Health: N/A 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 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 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 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 Yx 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. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than'/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (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 fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service 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 apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out'? X Were all system components,excluding the SAS,located on site? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARYI9,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 29,000/2001 35,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1.5.203): Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 1' Material of construction: X 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 certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: TAPE AND PROBE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE.NO SIGN OF OVERLOADING SEEN IN TANK. TANK AND COVERS V BELOW GRADE. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN, KENNETH JR. Date of Inspection: FEBRUARY 19,2002 TIGHT or HOLDING TANK: N/A (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/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 12"X 16",2' BELOW GRADE.BOX IS CLEAN,SOLID AND LEVEL.ONE LINE IN, ONE LINE OUT. NO SIGN OF OVERLOADING OR SOLID CARRY OVER SEEN IN BOX. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): 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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 -leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.COVER 2' BELOW GRADE.STAIN LINE IS AT 30". PIT IS DRY,NO SIGN OF OVERLOADING OR SOLID CARRY OVER SEEN IN PIT. CESSPOOLS: N/A (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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN, KENNETH JR. Date of Inspection: FEBRUARY 19,2002 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. Ile39 3/; Title 5 Inspection Form 6/15/2000 10 J Page 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 718 STRAWBERRY HILL ROAD CENTERVILLE,MA 02632 Owner: MCLEAN,KENNETH JR. Date of Inspection: FEBRUARY 19,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 10 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: X Observation 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 established the high ground water elevation: HAND DUG TEST HOLE— 10' NO WATER. BOTTOM OF PIT 8'.TEST HOLE 2' BELOW BOTTOM OF PIT. r 6 a//iM 3r /O/7T 7# I V,4 f R- Title 5 Inspection Form 6/15/2000 11 YOU WISH TO OPEN A BUSINESS? For Your Information_ Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G,L. It does not give you permission to opera e. must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FL, 367 Main St., Hyannis; MA 026.01 C wn Hall) and get the Business Certificate that is I „� required by law. I':wa ,(� ` OATS OZe—�` �. Fill in please: APPLICANT'S YOUR NAME/'S: � 'i� �r.>�: BUSINESS YOUR HOME ADDRESS: -7 K S+V R 6 ' 2 P\1 f iI 4 Y.r9 G � �JI� :1'IP•i •r��ti + - rr4 r' TELEPHONE # Home Telephone Number P IS 6 , ..11 i!$-Sc4, 11 #: NAME OF CORPORATION: NAME OF-NEW BUSINESSC,0, COD G2MVe V Q_ C-T1(D TYPE OF BUSINESS c_Q IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS..?) - MAP/PARCEL NUMBS 6 -(Assessing) When starting a new business there are several things you must do in order to b'e in compliance with th.e rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 t. - (Corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits acid licenses required'to legally a.perate a.ur usiness In.this town. 1. BUILDING COM%.Aut 'S OFF --, I IT rThis individu d f n r t r q reritsthet pertain to this type of business.`JIJ "�MPlYWITH HOME OCCUPATIOh�„���__ RULES AND REGULATIOIUS. FAIi_UrRE TO-�" COMPL.Y MAY RESULT IN FINES. e Sigriatur *" C MENT ,. .f go 2. BOARD OF HEA H B'L-- This individual has bee ed of the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL ut Signatur ** HAZARDOUS MATERIALS RECUI,:A -10.0, COMMENTS: z-V CfAaevt ` 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed ofthe licensing requirements that pertain to this type of busine ss. Authorized Signature COMME NTS: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�ALTI-IV Applirtatiou for Mipoii al Works To' nstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: /�/ ......... .... _�?..,/....-•----------•----- --•--•-•-----------•------•--................. /.Location:Address, or Lot No. .. .. ^ ... •--•----------------•--------•- --------- ----------------- Owner Address 'W1 ..•............ --------- - •- ------------------------•-------•------- ---------------------------------------------.....-.--------------•---•--•----•-----------..... Installer Address dType of Building Size Lot.....✓,.0_47Cq. feet U Dwelling—No. of Bedrooms............... .__._..___._____.______Expansion Attic ( ) Garbage Grinder A(VG3) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ____________________________ Design Flow......_......5_J.................. . y. . gallons per person per day. Total daily, flow.................. _, _.............gallons. W r r rs WSeptic Tank—Liquid capacityl.0-Wgallons Length_._..._.____ Width_____:____. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No------./----------- Diameter-------- .`___. Depth below inlet_._._6.......... Total leaching area.-C_0...sq. ft. z Other Distribution box (/ ) Dosing tank ( ) `-' Percolation Test Results Performed by........C1,? A§.......tS.fl�_/..�.. ............. Date...... /71.1.59 FO Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water______.______-_--------- L%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............... --- ----- • •--•-•-----•-•--••---•............................................•-•---•••---••••••......_................ ' x Description of Soil---------•--....0•-.o a ........_ ®l l ......S-��a...�-/2 --............................. -•--� --- -------------- ..--,-.......... --------------------- -------------------------- .....................................................=.................................................................................................. 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 TT T I_.L' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu y the board of health. n ned-• ------._.... D e ApplicationApproved By-•--.'-------- - •-- •-•-•-••-•••••-•-••-••----••----•--•---•••--•-••••---............ '-•. Date Application Disapproved f th following reasons-----------------------------•------•---------------------------------------------------=------------------------ ---•-----------------------------•--------•-•---------------••--••--•---------------------------------•--•-•---•----•-•••----•--••-------••-----•---------•-----•••-••-•-•--•-----------•--•••-•-------- Date PermitNo......................................................... IssuecL....................................................... Date ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T ..�t!�......OF...... .CI..1� �.71L. Applira#ion for Dispoti al Works C outitrurtinn tIrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- ..... -• ...----•-----.------•-- --••••-----•---••-•-••.................•-•-•-- .�,,� Location-Address or Lot No. Owner Address ----------- Installer Address U Type of Building Size Lot... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage.Grinder 4415) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) p I Other ifixAwes ------------•----------- -- W Design Flow t�C gallons per pers pe y. Total,cj l 'w - w. ------- f WSeptic Tank—Liquid capacit ___.__._____gallons Length"_____________ Width................ Diameter'V.._!�.___. Depth x Disposal Trench o_ ____________________ Widthir_r._.._...___._ Total Length_._.__.... ___ ....... Total leaching area....................sq, ft- Seepage Pit No------------------- Diameter.................... Depth below inlet...._ ___._._.___. Total leaching areaQb.....sq ft. Z Other Distribution box (®) Dosing Percolation Test Results Performed"by-_.______%__...__.__/_______________________ ...&_ _._______.______ Date_.__ / ,//_#..5?6 Test Pit No. I________________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........................ a of o S u s�1 ----� ' , ' --........................ Description of Soil______________ # W ••••---------------------- ----------------------------------------------------------•-------------------------------------------------------------------------- --•--------------------------•---••-- UNature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________ -----------------------------------•------------------------------------------------•---........--•---------------.---------...-----------------------------------------------•---------........._..---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �•1T/'1�^ the provisions of is 1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuby the board of health. ram. -11 Signed--- -----•••--- ��-----•-• Da e Application Approved By.......----• ?=. . ................................................................... ..<7/ -•-_-------- Date Application Disapprove or filie following reasons:---------••---•--•-------------•---•----•---• •-•-••--•-•------•-••-•-----------•--���--..........................-•---.._..---------------- ----•--•------••--------•-----•------------------------•---------•---••---...--•-•------..-.-.-----------I--------------•----••------.._.----•--•----..-.---•--------•----------------_.....----.-..•...- Date PermitNo......................................................... Issued------•-------........................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............7747-4UW....OF.. /�i ,/✓�/�/ ` , .................... Trrfifiratr of Tomph anrr If RJS IS TO CER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) - ---. ------------------------------------------------------------------------- at......... X............ .A4_ 17 has been installed in accordance with the pro on of TITLE 5 of The State Sanitary Co as escribed in the ........ dated_.application for Disposal Works Construction .ermrt No _ „ �' ____________________ THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BXCOANSTRS �GUA ANTES THAT THE SYSTEM WI F NCTION SATISFACTORY. DATE._..�d. . . .......................•--.......--•---•----•-_.. InspectoTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........1-- 4 GGL .....OF.. N........................... FE .. .................. �i��u��t1 rk� ��an,�#rn.�ilan rraati� Permission, hereby g`anted_? � ._� _c� r,_ ..__.............. to Construct ( ) or Repair an Indio al (Vage l5ysposal ern -- ....... - , �`-- --• ............./..........•- Sfreet as shown on the application for Disposal Works Constructio Permit No_____________________ Date. _._et .............. �� �� ...-•••-•-•-••-•-----------••• - •---- ..................` -•-••-••-- ........................ -- Board of Health DATE................... -----------••----•-•-•-•- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 19 0 W � W W N O. N O � 4 � b � W w N � ^ N W C W 3 4 N O ' i Hatg e at ac a v WIL "' o W SN U4 �. IL '�+• 0 TOWN OF BARNSTABLE LOCATION .7 l S T �"�E'��� /�rC L �� SEWAGE # VILLAGE C:C A- ASSESSOR'S MAP &LOT a it'S NAME&PHONE NO. r/f �� L �� e c _ SEPTIC TANK CAPACITY S £P/r C /oy 5�£C ; - a 0,2 . LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER d PERMIT DATE: COMPLIANCE DATE: rSeparat on-Distance Betwden 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 } I; �� � "'� �� ` •• � � `� 'I O w � �'I .J `C � �� '`� ... - � .. �. � .. �. W � u �� 1�� �� .� . .�. � 1 } ' w.W 5 - r ED, 25 J 35 1, + 72Y3 23+ z +5 z 14-4- -- M/nJ/MU/t.9 D �5 u 7- SEPTIC 5 y5 TE M CONS T2 UC T/ON e SHA L-L COn./FO/zA4 TO MA SS . OE 5/G Aj FLOW 330 CAL1 pAY _C-N✓ieon/ML/vrAL. Cook T/rL� P _ . - -_ �cl TE ' _ M/� /%/t/C,y _ LGAC TOP o� AIEAGTf-! REP DLE�C4CAPULATiONS p, 6r�.r-/'us7y F 12 6 E V L-ELtC Fo 7/CDn/ --- Z• � �M.oL l2✓/OClS Co vE MAN/-/OLE # Ca r/E,� TO' �k TEniZa 70 T� P2E✓Eti/T � W/ Tf-! 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