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Home My WebLink About0072 SUOMI ROAD - Health 72 ;SUOMI RD. RYA1ti NIS"' A 269- 106 0 0 I Sy Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every 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. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address 4 -� Sandwich MA 02563 mod"" City/Town State -Zip Code 03 508 364-0894 Pending Telephone Number License NumberLP o' B. Certification I certify that I have personally inspected the sewage disposal system at this address and hat the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority d'd• i �� October 25, 2006 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Inspectors Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure j criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. t5-2489.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 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 pipe(s) are replaced ❑ obstruction is removed t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 10.0 feet of a surface water supply or tributary to a surface water supply. 6-2489.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? SAS also evaluated ® ❑ 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)] t5-2489.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 71 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No 2 weeks ago +- Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2489.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)' ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 5+years. Disposal Works Permit issued 415101 (Board of Health permit#2001-205) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5.2489.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 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.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling 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: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 3 in Distance from top of sludge to bottom of outlet tee or baffle 31 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Permit application t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.): 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): t5-2489.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn f Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) I Tight or Holding Tank (cont.) j I I Dimensions: Capacity: gallons Design Flow: gallons per day i Alarm present: ❑ Yes ❑ No I j Alarm level: Alarm in working order: ❑ Yes ❑ No i 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert - At 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: t ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5.2489.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I I Type: i ❑ leaching pits number: ❑ leaching chambers number: �I ® leaching galleries number: l ❑ leaching trenches number, length: V ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining or standing effluent was observed in the stone t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): t5-2489.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis MA 02601 October 25, 2006 every page. City/Town State Zip Code Date of inspection D. System Information (cont.) 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. ° LEACHING GALLERY LOCATIONS 0 9 A B 1 27 Ft 23 f t 20 D-eox 2 43 f t 37 F t 3 50 Ft. 43 Ft SEPTIC TANK o i B n EXISTING DWELLING # 72 w Z J W I < a 1 SUOMI ROAD NOT TO SCALE t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 72 Suomi Road Property Address Shawn Flynn Owner Owner's Name information is required for Hyannis , MA 02601 October 25, 2006 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 15+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: Town of Barnstable GIS Department records indicate that the property is over 15 feet above groundwater table. I t5-2489.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 k4 �\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ,;` RECEIVED MAY 2 9 2001 TOWN OF BARNSTABLE TITLE S HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72 Suomi Rd_ HVannis, MA Owner's Name: James �arpns Owner's Address: 222 ly}�SBt Dr. MA Date of Inspection: — eD Name of Inspector: (please print) Wi 1 1 i am E_ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1 089 Centerville, MA Telephone Number: (5 0 8) 7 7 5-8 7 7 6 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 Sec ion 15.340 of Title 5(310 CMR 15.000) The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: L/ j Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthy DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the apprommi g 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. i I I Title 5 Inspection Form 6/15/2000 page 1 1 i Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ---- - r -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 0= V 1±; Mt PART A CERTIFICATION(continued) Property Address: 72 Suomi Rd. Hyannis Owner:' r, �ns Date of Inspection: /—�O—D I Inspection Summary: Check A,B,C,D or E/.ALWAYS complete all of Section D A. Syst Passes: 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: One or more system components as described in the"Conditional Pass"section need to be replaced or repa' d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please expla' e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist' tank is replaced with a complying septic tank as approved by the Board of Health. *A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ' g that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or o cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 tines a year due to broken or obst mcted pipe(s).The system will pass spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N explain: - I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Suomi Rd. Hyannis Owner: Carens Date of Inspection: 41—A O i 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 fai ' g 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 ystem 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 s tem 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. I _ 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 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. Other: i i 3 I I f Page 4 of fl ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Suomi Rd. Hyannis Owner: Carens ^ . .._ Date of Inspection: D. System Failure Criteria applicable to all systems:. Yo must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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 SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface .water supply. . Any portion of a cesspool or privy is within a Zone I of a public well. IAny 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 inter 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 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.] nYes/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 i Health to determine what will be necessary to correct the failure. E. arge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (The ollowing 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 II of a public water supply well If y u 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 fafled.The owner or operator of arty large system considered a sign scant threat under Section E or failed under Section D shall upgrade the system in accordance with 3.10 CMR 15.3 4.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Suomi Rd. HUnrini c Owner: Ca ran c Date of Inspection: 1�— Check if the following have been done You must indicate`yes"or"no"as to each of the following: Yes o � 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? _ _V Has the system received normal flows in the previous two week period? (/Have large volumes of water been introduced to the system recently or as part of this inspection? _ (/ Were as built plans of the system obtained and examined?(If they were not available note as N/A) r _ /�Was the facility or dwelling inspected for signs of sewage backup 1/ Was the site inspected for signs of break out? !/ _ Were all system components,excluding the SAS,located on site VI/ _ 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 .0 The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] j • j 1 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Suomi Rd. Hyannis Owner: Carens Date of Inspection: !Z—,'L o- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,,3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(far example: 110 gpd x 4 of bedrooms): .7,9 a Number of current residents: 0 Does residence have a garbage grinder(yes or no): v Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_,&, v Water meter readings,if available(last 2 yea-s usage(gpd)): 2000 77, 250 gal. Sump pump(yes or no): k 0 1999 80, 250 gal. Last date of occupancy: e COMM I CIAL/INDUSTRIAL Type of es blishment: Design flo (based on 310 CMR 15.203): gpd Basis of de ign flow(seats/persons/sgft,etc.): Grease tra present(yes or no): Industrial aste holding tank present(yes or no): Non-sani waste discharged to.the Title 5 system(yes or no): Water m ter readings,if available: Last dat of occupancy/use: OTH (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as padof the inspection(yes or no): d If yes,volume pumped:gallons--Haw was quantity pumped determined? Reason for pumping: 3 TYPE F SYSTEM eptic 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 installed(if known)and source of information:' a/ a —a I 13614 0 l �Z a,!L Were sewage odors detected when arriving at the site(yes or not-4,v 6 Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z? cuowi Rd Hyannis Owner: Q a. Date of Inspection: Q:imoo— B LDING SEWER(locate on site plan) Dep below grade: Mat rials of construction:_cast iron _40 PVC_other(explain): Dis nce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: V(locate on site plan) 1% Depth below grade:Z¢_ � Material of construction: v`oncrete 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) I ► L Dimensions: G !oa 1 b Sludge depth: 6 ` 1 Distance from top of sludge to bottom of outlet tee or baffle: _ 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: f t/ How were dimensions determined: A,L' / Comments(on pumping recommendations,inlet and outlet tee or baffle_condition,structural integrity,liquid levels as related to outlet invert,evidence of)eakage,etc.): GRE E TRAP:—(locate on site plan) Depth elow grade:— Materi of construction:—concrete—metal—fiberglass_polyethylene—other (explai ): Dimen ions: Scum ickness: Dista ce from top of scum to top of outlet tee or baffle: Dis ce from bottom of scum to bottom of outlet tee or baffle: Da of last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rel ted to outlet invert,evidence of leakage,etc.): I 7 Page 8 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Suomi Rd. Hyannis Owner: CarenG Date of Inspection: Gl—;Z-{S"0 I j T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mater 1 of construction: concrete metal fiberglass polyethylene other(explain): Di)olast ns: Ca gallons Delow: gallons/day Alesent(yes or no): Alvel: Alarm in working order(yes or no): Da pumping: Cots(condition of alarm and float switches,etc.): I � DISTRIBUTION BOX: V/of 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.): PU)working HAMBER: (locate on site plan) Pu order(yes or no): Alaworking order(yes or no): Cos(note condition of pump chamber,condition of pumps and appurtenances,etc.): ' t 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: 72 Suomi Rd. Hyannis Owner: Carens Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: I i Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: { leaching trenches,number,length: leaching fields,number,dimensions: I 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 pumped as part of inspection)(locate on site plan) L Number and configuration: Depth—top of liquid to inlet inve . Depth of solids layer: ✓ 1 Depth of scum layer: k i 4hL 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.): PR (locate on site plan) Materi s of construction: Dime ions: Depth f solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C A SYSTEM INFORMATION(continued) . Property Address: 72 Suomi Rd. Hyannis Owner: Carens Date of Inspection: L�•-�-G'O� 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' 7 � 4 L� SD I . 10 i Page 11 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Suomi Rd. Hyannis Owner raI-o., Date of Inspection: —aZ-o--�' 1 SITE EXAM Slope_ Surface water Check cellar Shallow wellsae _ Estimated depth to groundwater /it feet i I Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: I You must describe how yoy established the high ground water elevation: I' p I " I I i; i I'. K j I i �I �r is ' t 11 �I, TOWN OF BARNSTABLE LOCATION SEWAGE #(5r!_ VILLAGE ASSESSOR'S MAP & LOT "J40 INSTALLER'S NAME&PHONE NO. F, el:,X s 7 S'—F 77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)OZ'" J �`S`� G' C (size) NO.OF BEDROOMS 2-.-z BUILDER OR OWNER C w -? PERMITDATE: `/-S.o COMPLIANCE DATE: ate)" b I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I �1 . �0p�� f ti n .. �� . � r� � G _ .1 __ � t _ ��--_ i �� .. No. X0 I_d VJ F�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for Migoza[ 6potem Construction Permit Application for a Permit to Construct( )Repair( ))Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 72 Suomi Rd. , Hyannis James Carens i Assessor'sMap/Parcel Z6 _ D` 222 Eisenhower Dr. , Cotuit f� i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville 4 i Type of Building: Dwelling No.of Bedrooms 8 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow gallons per day. Calculated daily flow gallons. ` I Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil;Sand i 1 Nature of Repairs or Alterations(Answer when applicable) ' Title-5 septic system consisting of a 1 , 500 gal. tank, b—box and 2 precast leach chambers with stone all around. 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 Certifi- cate of Compliance has been issued by this Boardof Health.. Signed � � ,/f-- Date �2— Application Approved by `1(.Q/L' SCk_QCb�o r ykp\4 Date O � Application Disapproved for the following reasons Permit No. 000)CX)s Date Issued 0 . _- �- ,.F.-�,r....` -e.�,.y�•�_.7�'•a:q,�-r.�:--air+..---- .- -. =F� --�a�=- - -w.-e i�(-vfi•-:� `--.--�.+w•.+..�.a�r....+._..r.•,.d.- - - - - No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �.-- ,s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Mtootal *proem Corigtructton Vermtt Application for a Pen-nit to Construct( )Repair( X)Upgrade( )Abandon( ) El Complete System El Individual Components E Los/a�onAft%yL? go. I Hyannis `£� Ja[Tle3 arenSdTel.No. Assessor'sMap/Parcel Z.6C/_/D6 222 Eisenhower Dr. , COtuit Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E'. Robinson Septic Service P O Box 1089, Centerville , Type of Building: ,. Dwelling No.of Bedrooms 3 Lot Size 6 r sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets . Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil-Sand !, r 1 —d f� f Title-5 septic system Nature o e airs or Alter ons( nsw r when pplicable: c�nspisting o� a 1A, 5�0 ;ga�.� i.ta ; .s- ox ana precast leaV 1 ith 1 tr Date last inspected:- Agreement: r.. The undersigned agrees to ensure the construction and maintenance ofithe afore described on-site sewage disposal system in accordarjce with the provisions of Title 5 of the Environmental Code and?not to place the system in.operation until at grtif Cate of Compliance has been issued by th' oar of Healt tj f" f Signed P� / —` Date 1L�-�,S d - '_ Application Approved by1 '� � 'b� �4 �N�1J Date .'Y S1 O 1 y Application Disapprow�ed gr following reaso r� r +1 l ""' 3 r Permit No. ° / '�f .! 1 ateiIss ed/ / jo -----------'f� ----------k. ---_-------- fTHE COMMONWEALTH OF MASSACHUSETTS j BARNSTABLE, MASSACHUSETTS Carens "-�• ? + �� Certiftcate of Comphance 1=: THIS IS TOFERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Aband d ., lb m. E. Robinson Septic Service- ,--,. at � uimyi Rd. , annis _� een constructe i accordance with the provisions of Title 5 and the for Disposal System Construction Permit.No.aL'l dated y Installer Vm. E. Robinson Sr. Designer The issuance of tl � erm��it be construed as a guarantee that the sys e rll fugetr__ desig d,&Date Inspector '' ( s " is — 0�05 -----------�------------ ---- No. Fee �001 � TH 0OMMONWEAL'TH-OF/MASSACHUSETTS 1 6 , PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Carens Mtopool *potem Con5tructton Vermtt Permission is herebyfrasudoto ongctTct H�iai�it )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. r Provided:Construction must be completed within three years of the date of this permit. Date: Approved by � I Il6J99 ' NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CE fMCATION OF SKETCH AMID APPLICATION FOR A DISPOSAL WORKS CONSTRUMON PERMrr OkTMOUT DESIGNED PLANS) L William E_ Robinson.Sz y certify that the application 6r disposal works construction permit signed by roe dated �f,-- S- • conceming the property located at 72 Suomi Rd. , Hyannis meets aA of the Mowing caketia: • The failed system is aon wed to a residential dwelling only. There are no commercial or buancis uses associated with the dwelling. The soil is dassi5lod 1 and the peroolatiazs rate a tzss than.0 equal to:-)mimues per inch There arc no wetlands 100 feet of the proposed sgMC stistem Thera are no private ells wtthsn 150 IetY of the propose septic sS'stem There is no i in flaw and/or change in use proposed • There are no requested or needed • The banam the proposed leachin8 facility will n9t be located less than five feet above the matimum gconndarater table elevation:[Adjust the groundwater table using the Frimptor method applicable) • 1f the S_.3LS_will be low with 250 feet of any vegpaced wedands.the boanrn of the proposed leaching f c lily will M be located less than fourteens(14)feet above the maximum-adjusted groundwater cable elevation, Please complete the fill arieg: JJJJ A) Top of Ground Sn>faOC E (using GIS in malkm) B 1 G.W.Elevation +the MAX. f figh G.W.Adjusunew DIFFERENCE BETWEEN A and B �G SIGNED: L/�' DATE: -—6 / (Sketch proposed Plan of system on hack[. y:health fokkr ecit i ;� s- C (\`�\ G V"' ` V d F� �' . _._... .... •.. i y, { TOWN OF BARNSTABLE. } LOCATION SEWAGE # VILLAGE_ �/ r ASSESSOR'S.MAP & LOT' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) Z— e— (size) �•� S— NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: S- 0 7 COMPLIANCE DATE: /—o'?,a— 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet' Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Fw7n shed.by-- i /G. 3 \ t , Vr TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT — INSTALLER'S NAME & PHONE NO._ ja SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) !X1t __ NO. OF BEDROOMS_ .2� _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED:i /5-— DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No __ I /' w � �� l sue. i y !(�' l �, � i .. l \ � _ 1 ' . . \ \ _, I � �� o� �. (�� \ � � V` � � Y r �� \ - � i THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF _HEALTH !s?✓y.........OF.... �GG•y5Z&-, .... ................................................ ApplirFatiall for DiopooFal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (1,-Iran Individual Sewage Disposal System at: 7.2 r ................---•-•---...................S�C?f?:+1...!:._..... /..! .htl...i ................................................-- ia ..................•..... . ............ Loca' n- ddress Ltf ill -.. .... .!---12..... ........................ ow s� ne / d r a �P4i.i.......7p.... 1.!�....................I.......... .. ........... u.rX._/.._._._.............................._.. Installer Address UType of Building Size Lot............................Sq. feet Dwelling.* No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons..........--.........--.---. Showers ( ) — Cafeteria ( ) Q' Other fixtures .......-.--------------------------•------------------•Q W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter...----......... Depth................ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area...................sq. ft. 3 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......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... : .............•-•----•--...---------•-•-•---•.........--------------.._...................................._.......---•_--_.. O Description of Soil............................ �Gt ._.... U -----•----•--•----•--•-------------•--••••......-----......... --...........••----.....----------------------------............-- -------•------ ----••---.............. W V Nature of Repairs or Alterations—Answer when ap livable... Gdt� le�L c4_�u r / .------•------f � ....�oj� ,�� -------------------------------------------------------------------------------------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sslied by the board of h th. Signed.------ .............�-- -----------------------•---•-- Date Application Approved By...... �� ...... -•----... Date Application Disapproved for the following reasons--------------------------------------------------------------•--•---------------------......----•-•-•-._........ ---•---•-•...................•---....----.....--•------------•---•--•--•-------•-----........•--•---------•-------------••-•----•---•---•--•---------•----•---•---•---------•--••-----------•-•--.....-- q Date PermitNo......... ._(_'- U..................... Issued_....................................................... Date No.......04- FES........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T�� ,��`HS 0 le ...........................................0 F..........................................................-----------..........------•---• Appliratiun for 11itipaii al Works (famitrttr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair (lean Individual Sewage Disposal System at: d ................_........_...................................................................... ..............---•-............---....----•---••--•----•--...------.........................--.••. Location-Address a - or eLoot No. i -� ...........�!{�PP'�'/ . !� .A.`1 fit! .......... ..... 'it !?lQ j... .. � �?.S 7� s ...... a ��f�l!2.__.. t_..ot7CJ�(G...... ...................... . 1..1 _W.4.A.tt A r / ......_.. � Installer Address Type of Building Size Lot............................Sq. feet Dwelling-' No. of Bedrooms...........-�Z...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g •=--•----------------------- P ( ) — Cafeteria ( ) dOther fixtures --------------------------------------•--------•--•---.--------•-•----•-••------•-----•--•-•---••--------...-•-••----••----------------•-•-•.......... W Design Flow...........................................:gallons per person per day. Total daily flow..;......::.................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................. Width..............:. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ .� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --••----•-••----•-•---•••-••--•--•................•--••--•----......------------............._------.....................................• *................ O Description of Soil.................._ . -Description f - -------------- � -------•-- V -- ---•-------------------------------------------------------------------•---------------------....-------•••---••---•--••-•--•--•-•-- W UNature of Repairs or Alterations—Answer when applicable__,lhS. l�._�e✓,?P.) t-W..... ------------------------------------- ------.V 4-.---.5 .'elaW ••- •----••••------••-•--•--•--------•------•-•--•••••--•-•-----•••-•--••-•-••-----••---•-----.....--.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee su by the boardAli.,elthh,..Signed -- ••. ( ` lJ Date Application Approved By................. -- 6,.�t y. Application Disapproved for the f o owing easons:-----•••••-•------•--••--•-•--••...............••-----•----•-------••---•-=-•--•-------••-•--• •---••.......... ----------------------------------•-----_•--........-•••------....-----••••---••---.........-•-----------.•------•---•---•-----•-----•-•------------•------....---•----•-------•---•----•••-----....-•--- q Date PermitNo...........� ------------------- Issued-....................................................... Date ^ THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH t .......... ......O F............ � 4, C'............................. t- z:� (Irrtifirtt#.e k Ii41 THIS I TO . ERTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired by------------------- .------. --------------------------------------------------------------•-----------------------------------------.•------------------------ Instal ler at ...7- •••... 1�- j': I ----------------•-•------- has been installed in accordance with the provisions of _Imp. j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....$-9.- --a-,c dated................:............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............•.....C....... _ ......................... Inspector.................... G ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ...Oy lr ...........OF............ y. . f '--�,g ......................... .. iu uTRvrVftmdxudivn "rrutit1 Permissi is hereby granted . •-•-••• ----------------------==---••-----..__........._.__. j:. to Construct �Rep�� ndivgsju�l Se��I 'Disposal Sy stem atNo �t`6`� E ............................................•--------------------------------------.......----- Street p as shown on the application for Disposal Works Construction Permit G`a.".4 '�` .�_.._. Dated.......................................... •.....................••--•-------- - -------------------------------------------••---------••-- Board of Health DATE................................................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i