HomeMy WebLinkAbout0080 SUOMI ROAD - Health O..'suomi Road
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TOWN OF BARNSTABLE
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SEWAGE #
VII L"AGE LlS ASSESSOR'S MAP & LOTa69 5..3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
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LEACHING FACILITY: (type) Pi �oX Co (size) l t
NO. OF BEDROOMS
BUILDER OR OWNER ACM) AIC-rc4d 0
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE.5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 80 Suomi Road
Hyannis.MA 02601 '+
Owner's Name: Michael DanQelo r
Owner's Address:
Date of Inspection: March 27, 2008
Name of Inspector:(Please Print)James M. Ford
Company Name: - James M.Ford 0
Mailing.Address: P.O.Box 49w` �� t
Osterville.MA.02655-0049
Telephone Number: (508)8624400 . '
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 bf 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
eeds Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: March 28, 2008
The system inspector shall su mit a copy of this inspection report to the Approving:Authority(Board of Health or
PEP)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,
Notes and Comments
****This report only describes conditions at.the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Michael Dangelo
Date of Inspection: March 27. 2008
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 irmninent. 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
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:
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Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis. MA
Owner: Michael Dangelo
Date of Inspection: March 27, 2008
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 aseptic 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 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:
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Michael DanQelo
Date of Inspection: March 27, 2008
D. System Failure Criteria applicable to all systems:
You must indicate either"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 ari 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 '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of tunes pumped_.
✓ Any portion of the SAS,cesspool or privyis 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.
✓ 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 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.]
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 System*
To be considered a•large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following.criteria 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 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.
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Page 5 of I 1
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 Suomi Road
Hvannis. MA
Owner: Michael DanQelo
Date of Inspection: March 27. 2008 .
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 twomeeks?
✓ _ 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?
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Deternined 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)].
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 80 Suomi Road
Hyannis. MA
Owner: Michael DanQelo
Date of Inspection: March 27. 2008
FLOW .CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310.CMR 15.203 (for example: I I0 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years'usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAVINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):. gpd
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 infonnation: Unavailable
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
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:
Date of installation unknown.
Were sewage odors detected when arriving at the site:(yes or no):. No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Suomi Road
Hyannis. MA
Owner: Michael Dangelo
Date of Inspection: March 27. 2008
BUILDING SEWER(locate on site plan) .
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Coimnents(on condition.of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: Cover to grade
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) cesspool block
If tank is metal list.age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth: --
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to'bottom of outlet tee or baffle:
How were dimensions.determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet.invert, evidence of leakage,etc.):
The liquid level was up to the outlet tee. The cover was to grade
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Coimnents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Suomi Road
Hyannis,MA
Owner: Michael DanQelo
Date of Inspection: March 27. 2008
TIGHT or HOLDING TANK: None (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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Suo,ni Road
Hyannis, MA
Owner: Michael Dan elo
Date of Inspection: March 27, 2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
i
Type
✓ leaching pits,number: 1=1000.gaL
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.):
The pit was dry and clean There did not appear to be any signs offailure The bottom to grade was II' The cover was 12"
below.
CESSPOOLS: None (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):
Commnents (note condition of soil,signs of hydraulic failure,level of ponding;condition of vegetation,etc.):
PRIVY: .None (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.):
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Page 10 of. 41
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Suomi Road
_ Hyannis. MA
Owner: Michael Danzelo
Date of Inspection: March 27. 2008
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.
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Page 11 of 11
A
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address: 80 Suomi Road
Hyannis,.MA
Owner: Michael Dangelo
Date of Inspection: March 27. 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25+/- feet
Please indicate(check)all methods used to determine the:high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours Wraps
Checked with local excavators, installers-(attach.documentation) .
Accessed USGS database-explain:.
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours snaps, the ntaps were showing approximately 25'+/-ground water at this site.
This report has been prepared only for the septic system and components described herein. This septic systen:has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees,either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected. .
11
COMMONWEALTH OF MASSACHUSETfS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P_ROTE_CTIO_N
rWCEIVED
MAR 17 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 80 Suomi Road
Hyannis, MA 02601
Owner's Name: Ariel Mercado
Owner's Address:
Date of Inspection: March 1, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:269
Osterville,MA 02655-0049 Parcel. 153
Telephone Number: (508)862-9400 Lot:42
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:
✓ Passes
Conditionally Passes
Need urther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: March 5, 2003
The system inspector shall sub t 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1. 2003
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
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:
2
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1. 2003
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 I 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 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either`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 '/z 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 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 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.]
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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or"no"to each of the following:
(The following criteria 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
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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.
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Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 Suomi Road
Hyannis, AM
Owner: Ariel Mercado
Date of Inspection: March 1. 2003
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?
✓ _ 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:
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)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4- per disposal permit Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 3
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): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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: Pumped approximately 6 years ago-per owner
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
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:
A leach pit was added on Jul. 13182-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Suomi Road
Hyannis, AM
Owner: Ariel Mercado
Date of Inspection: March 1 2003
BUILDING SEWER(locate on site plan)
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 on site plan) (Cesspool acting as a septic tank)
Depth below grade: Cover to grade
Material of construction: _concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: S'W x 5'T x 8'bottom to grade
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: —
Scum thickness: 10"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: —
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
The liquid level was up to the outlet tee. The cover was to grade Recommend pumping
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1. 2003
TIGHT or HOLDING TANK: None (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: aallonstday
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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (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.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Tye
✓ leaching pits,number: 6'x 6'- 1000 gal.
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.):
The pit was dry. The scum line was approximately 2'up from the bottom. There were no signs offailure. The cover was
approximately 12"below grade. The bottom to grade was approximately H'.
CESSPOOLS: None (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: None locate on site plan)
( P )
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
i
..c Page 10 of 11
V'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1. 2003
Map:20
Parcel: 153
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:42
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.
A �
I
a
10
:.� Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Suomi Road
Hyannis, MA
Owner: Ariel Mercado
Date of Inspection: March 1, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +1- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. -
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of pro erty y v m
Owner's name 4 A � S c e.g� °0.
Date of Inspection
PART A
CHECKLIST
7e�cjf the following have been done:
Pumping information was requested of the owner, occupant, and Board of
lth.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have' not been introduced into the
ystem recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
V The facility or dwelling was inspected. for signs of sewage back-up.
_I,:::f_ The site was inspected . for' signs of breakout.
system components, excluding the SAS, have been located on the
mite.✓ _ .The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
s udge, depth of scum.
i The size and location of the SAS on the site has been determined based
existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ON'' FOR.M�
PART B
SYSTEM INFORMATION ;
I
fI 1
FLOW CONDITIONS
If residential
number .of bedrooms
number of current residents
1 o garbage grinder, yes or no
laundry connected to system, yes or no
_Q seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: ( 9R ( a�" l�
Lk (X °
115 Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information: 1
C,�. "i
es. System pumped as part• of inspection, yes or no
if yes, volume pumped G G 0 3N s ,
Reason for pumping: `
�� Op c eSs G,p S 5 Qr
Type of system 1
Septic tank/distribution box/soil absorption system
Single cesspool
_ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age ``oft1 all components. Date installed, if known. S.ource of
inf �Qc►11 �141 —
f� L MJ J
e m
Sewage odors detected when arriving at the site, yes or no
• I
9
\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: N
(locate on sit plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions:
sludge dept
distance fro 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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrit ,
evidence of leakage, recommendations for repairs, etc. )
rN5 t 'e
`p fit,ci,,.-S v , '- --E� r�c-e -`h'l.lc d �� �.,�- (( � A 2S
DISTRIBUTION -BOX: co
(locate on site pla )
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER: N
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
_z
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type. n
leaching pits and number
leaching chambers and number � �' s ►ve - � '-1
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number C.e Ss PCi0 ;
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition f vegetatio recommendations for mna .ntepance o3F repairs et . )
u CLS 0- OC
w U k4
9 � '� 1 5 �� 1 •��,,�-� ��,.,� l.c�1Z S. �d d
CESSPOOLS (locate on site plan) :
Pa-
number and configuration
— ss ���S _ I reccst teac.
depth-top of liquid to inlet invert e_
depth of solids layer
depth of scum layer ------
dimensions of cesspool 71.
. materials of construction—_-
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate o site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FARM
PART B
SYSTEM INFORMATION continued '
SKETCH OF SEWAGE r_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Q� t
37
Na'
A sC
S 36. it
DEPTH i
DEPTH TO GROUNDWATER
depth to
p groundwater
method of determination or approxim t^ion: 1- n
ti ti� W cti�ti-• ` TU l.vJ� S ° �.1 S�c'4 �D ' '1'�°NJ J
`5 � L s
j 2�
_ r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping- 4 times or more in the last year?
number of times pumped
N Septic tank is metal? cracked? structurally unsound? substantial ,
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
i .
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analySiL
for coliform bacteria, volatile organic compounds; ammonia nitrogen
and nitrate nitrogen.
TOWN OF C'f•%S BOARD OF HEALTH
`• �� . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
—TYPE OR PRINT CLEARLY— -.—..----.T --------- _----
PROPERTY INSPECTED �` \
STREET ADDRESS J �A 0 rYl'\
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAM
PART D - CERTIFICATION
NAME OF INSPECTOR O.'f
COMPANY NAME
COMPANY ADDRESS I 935 kI)kte ( 30 MC\S leP r(1QcS, Oa�yq
Street Town oii City State LIPS
COMPANY TELEPHONE (_5G ) 14 -]- - '7 (o a G FAX
CERTIFICATION STATEMENT ;
I certify that I have personally inspected the sewage disposa-1 system r
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are 'consistent
with my training and experience in the proper fiinction and maintenance of or
site sewage disposal systems .
Check ne :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails t
protect the public health and the environment in accordance .with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
0
Inspector Signature , Date gv
-1 q''
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.do
r3.
LO CAT ION g SEWAGE PERMIT NO.
op
VILLAGE
INSTA LLE 'S NAME i ADDRESS
i
6UILDEIII
OR 0W
NER
DATE PERMIT ISSUED
rZ-)3-8z
DATE COMPLIANCE ISSUED;
i
O
0 �
I
i
O 77
. T•
.i
N� .....- Fxs ...5:0.�........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...............T ow..a.......---.....O F...................Barnsta.ble...........................................
. pphra#iun for Biupuuttl Works Tuntrnr#iun "ami#
t
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
...8.Q.......��znlns...E oarlT..H�ranna.�r 1 -L12b0�--•------ --------------------------•------.--•--------•------------------------..........----------•--•---
Location-Address — --- — or Lot No.
hes.v_i..Y-aha kaangas..................................................
............................................. us�mi..xd-..,...H�!a nnis,..MA.....D260�
Owner Address
aA & B Cesspool Service j........................................ .128..Bishags...Te=ace.,...Hya,nnis,._MA...Q26Q1......
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling--No. of Bedrooms............._...........................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons........ ................ Showers — Cafeteria
P4 Other fixtures ................................. .
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width.................. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft.
�r Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0-4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 .....
.-•Sam----------------------------.-------- • -----•-------._...._....---•-•--......_....-•------•--••--------•---.......-•--•--•-•-•------.....
Descriptionof Soil........................................................................................................................................................................
x
w
UNature of Repairs or Alterations—Answer when applicable..:Lnstal]aticn__of..a..1.,.QQII_.gallon.,-__pm—cast
stone acked leach Ditp ••:(•overfl Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health.
SignedL ,YC..
D to
Application Approved By.............— -'J�- � •. ....................... ..................7-7134Z.....
Date
Application Disapproved for the following reasons:-----••------------------------------------------------------------------------•-----------------------...........
.............
-............................
•............
-.......
.-------------------------
...__....------------------------------------------------------•------------------------
----------------
Date
Permit No...........82-............. Issued... 7
/8 2.................
Date
%2
N ....... FEB$ .... .....00.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............T-01M.................OF.................au-nata-ble.............................................
Appliration for Disposal Works Tonotrurtion thrmit
Application is hereby made for a Permit to Construct or Repair 6c ) an Individual Sewage Disposal
System at:
.........Lclil=e..�Rcad,...ii iz,-244.....02-6061.......... .................................................................................
7 .....................................................
orat'Address or Lot No.
7 ....xTA.....o26ot
Owner Address
W A..& B Cesspool Service. 'Riab.... .......................................................................................... 128.. op-s..Merraae,..HVmrmis.,-..YA---D2Lal........
�-4 9Q Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............4.............................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons.......4.................. Showers Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid'capacity............gallons Length................ Width........_._..... Diameter._._.__..__..... Depth......_.........
Disposal Trench—No..................... Width............._..._.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.._................. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit___.__.............. Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit__................... Depth to ground water........._..........____
---9.. ...................................................................................................................
ica----------------*"*....***'*
0 Description of Soil.......................................................................................................................................................................
U ....................................................................................................................;....................................................................................
W
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicableAmtallation...of---a..-1..0.0 0---gmllon,...pm.-Tmat,
...pit...(.9 .910.............................................................................. .........................................
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 been issued by the board of health.
/- d... .........
...!1e
Signed.................... ...............
te
Application Approved By............. .................7AO/M......
Date
Application Disapproved for the following reasons:................................................................................................................
..........................................................................................................................................................................................................
Date
Permit No....................................................... IssuedL.....................7113/�?..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable 'k
........................................ OF.....................................................................................
T W rtifiratr of Tautpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (X
by....
p.*..T ..........................................
at.................................................I............... . .. ..........
jhAk ............................................................
80 Suomi Road, Hyannis. MA 0260 Installer
has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Code as described'i.n the
application for Disposal Works Construction Permit No.82-......... .......... dated....7/13/8?.........../.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE.
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....__.?/j�/82 S _j
.. ............................................................. Inspector................................. A
.......... ......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T own
...........................................0 F................Parristable..........................................
Noel......7215. .........
Disposal Work,5 T-511notrudian omit
PermiPermission V
ssion is hereby granted....A... B...0.0 ra ra P.O.Q1.'9 wy I-a a......................................................................................
to Construct or Repair et ) an Individual Sewage Disposal System
at No... 8P Suomi Rod
.........................
as........................................................
Street 82- 1 � 7/13/82
asshown on the application for Disposal Works Construction Permit No..................... D�ated ,...............................
/'ox! .................
Board edrth
DATE............. 7/13/82
................................................................
FORM. 1255 HOBBS & WARREN. INC., PUBLISHERS