HomeMy WebLinkAbout0123 WOODLAND AVENUE - Health 123 WOODLAND AVE., EXT.,HYANNIS
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' TOWN OF BARNSTABLE
LOCATION 1 D&a�f/ �� G SEWAGE# TN5P
VILLAGE AS SSOR'S MAP&PARCEL
FAR' NAME&PHONE NO.
SEPTIC TANK CAPACITY et'.
LEACHING FACILITY. (type) ��� �� (size) '
NO.OF BEDRO MS
OWNER
PERMIT DATE: GQ44PEtkNff DATE: a,,( D y ZO I3
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
f J I r f ! r J f J rf f J f f r ! ! J r r r r f f r f r
f ✓ f f
f f f J
• \ • •
f r f J -
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,. ; 30
25
31
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1'FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: Oc51 0011 I dl C>�
Fill in please:. °
APPLICANT'S YOUR NAME: 2
- BUSINESS YOUR HOME ADDRESS:
TELEPHONE # HomeTelephone Number
NAME OF NEW BUSINESS i ,t> G G-X- -tU i e-Qi TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? _YES NO
Have you been given approval from the building division? YES NO
ADDRESS OF BUSINESS k2,B OJOO- . OPP—, L MAP/PARCEL NUMBER
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONE 'S OFFICE MUST COMPLY WITH HOME OCCUPATION
This individual has been inf d of any it requirements that pert to this type of busi� S AND REGULATIONS. FAILURE TO
Authorized Sign ur ' COMPLY MAY RESULT !tJ FINES.;
COMMENTS: P
2. BOARD OF HEALTH
This individual has,�enn informed&oh permit requirements that pertain to this type of business. I ou
Authorized Signature*
:-r
COMMENTS: .
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of.business.
Authorized Signature**
COMMENTS:
._t
' Town of BarnstableR�EcEIPT
Lx 1 200 Main Street, Hyannis MA 02601 508-862-4038
Application for Building Permit
Application No: B-17-210 Date Recieved: 1/25/2017
Job Location: 123 WOODLAND AVENUE,HYANNIS
Permit For: Building-Home Occupation
Contractor's Name: State Lic. No:
Address: , , Applicant Phone:
(Home)Owner's Name: OLIVEIRA,LAIZA M Phone:
(Home)Owner's Address: PO BOX 96, CENTERVILLE,MA 02632
Work Description: Laiza Cleaning Service
Total Value Of Work To Be Performed: $0.00
Structure Size: 0.00 0.00 0.00
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: OLIVEIRA,LAIZA M 1/25/2017
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost.: $0.00
Date Paid mount Paid Check#or CC# € Pay Type
Total Permit Fee: $35.00 1/25/2017 $35.00 cash
l .__....... _..........._........
Total Permit Fee Paid: . $35.00
�:r„<^a•..3�..m£�&„uk_.��.",�,cnnu.�```.. �5.,.„3.�. u.`".,..t'�...mow, .d.��!'.L..x..t�z'�e.e.,. .,.,n,.�?i��. .�..._��,�,".c.. ,r.5"t.....�., .,�.sa ,�.T.i
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Town of Barnstable
Regulatory Services
FZHE 1p�
tic Richard V. Scali,Director
+ RAxivsrwsr.E.
Building Division
M� $ Paul Roma,Building Commissioner
�'DrEo aim 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Approv d: —
Fee:
Permit#:
HOME OCCUPATION REGISTRATION
Date:
Name: I � 6� Phone
Address: i '✓ JCJ ncdQ Y Oa� Village:
Name of Business: G Gl CA corn I -ra Jl�,eA U I U—)
Type of Business: C�1 ap/Lot:
INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the 4
activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual
alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,located
within that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there
is no outside evidence of such use:
• No traffic will be generated in excess of normal residential volumes. '
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular
matter, odors,electrical disturbance,heat,.glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess
of normal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There are no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling t.
I,the undersigned,ha eIread and agree with the above restrictions for my home occupation I am registering.
Applicant:
Date:
Homeoc.doc Rev,VO/
Date:
TOWN OF BARNSTABLE •{
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
A O G
NAME OF BUSINESS: n l `,5 C I
BUSINESS LOCATION: t «.. tf)�,c�� tlx ,.,�.. ��^,�t? , 4A0.)Nc'8_'kS' V% f!,--LO INVENTORY
MAILING ADDRESS: �,�'�-�•-�1.�> TOTAL AMOUNT:
TELEPHONE NUMBER: r,
CONTACT PERSON: koj'- . l
EMERGENCY CONTACT TELEPHONE NUMBER: .I ck y k_/ MSDS ON SITE.
TYPE OF BUSINESS:
INFORMATION / RECOMMENDATIONS.J Fire District:
i
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
i
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids) ;
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's/Signature Staff's Initials
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden -
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
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. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell ��Y
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648
NRun City/Town State Zip Code
508-428-1779 S1 12855
Telephone Number License Number
B. Certification
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:
®
C:)Passes El Conditionally Passes ❑ F C7
❑ Needs Further Evaluation by the Local Approving Authorityd? a
March 4, 2013 Job# 3-12 -Ya
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approvi g Authorityo(Boar�
of Health or DEP) within 30 days of completing this inspection. If the system is a shared syst_6m 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. I/
t5ins•11110 Title 5 Official Inspection o m: UbSUlfaLe Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w.w 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
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:
® 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:
Tank was not in need of pumping at time of inspection, leaching pit showed no signs of saturation or
surcharge.
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11I10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts Inspection Form
Title 5 Official Assessments
a
- Subsurface Sewage Disposal System Form Not for Voluntary
�M 123 Woodland Ave
Property Address
Karen Ha den - —�—
Owner Owner's Name MA 026_ 01 ___ March 4, 2013
Date of Inspection
information is Hyannis State
Zip Code
required for CitylTown
every page. B. Certification (cont.)
Supplier, if any)
in a manner that protects the public health,
2. System will fail unlessBc ioof n ngalth (and Public Water upp
determines that the system sun
safety and environment: system (SAS) and the SAS is within
❑ The system has a septic tank and soil absorpttona surface water supply.
0 feet of a surface.water supply or tributary
tank and SAS and the SAS is within a Zone 1 o
The system has f a public water
10 a septic
❑ supply. private water
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a p
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee or
more from a private water supply well**
Method used to determine distance:
for
cal
**This s stem passes if the well water analysis, performed oni ni rogenlanded Intate nit genes equal
Y
coliform bacteria indicates absent and the presence o a of the analysis must
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
t5ins-11/10
Commonwealth of Massachusetts
U W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,w 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
Yes No
❑ ® 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 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 f
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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for --
every page. City/Town 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?
® ❑ 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)]
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):
330
i
t5ins-11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1
Number of current residents:
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
172 gpd.
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied.
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:
15ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis H MA 02601 March 4, 2013
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Unknown _
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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
15ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
8"
Depth below grade: 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
8.5' long x 5.2'wide - 1000 gal.
Dimensions: ---
1"
Sludge depth:
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is required for Hyannis MA 02601 March 4, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
29„
Distance from top of sludge to bottom of outlet tee or baffle
Trace
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6
14"
Distance from bottom of scum to bottom of outlet tee or baffle
Measured
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was at bottom of outlet invert and tees were intact.
I
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
I
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
t5ins-11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for State Zip Code Date of Inspection
every page. City/Town
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis _ MA 02601 March 4, 2013
required for State Zip Code Date of Inspection
every page. Cityfrown
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
0"
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.):
No solids or high stains present No evidence of surcharge found.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 123 Woodland Ave --
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013.
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Type:
One 6x6 pit
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Area of leaching pit was probed with no evidence of saturation found, probed into stone and probe
was found dry.
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
t5ins-11110 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 123 Woodland Ave _
Property Address
Karen Hayden
Owner Owner's Name
information is required for Hyannis MA 02601 March 4, 2013
-
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts -
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
123 Woodland Ave
Property Address
Karen Widen
Owner Owner's Name
information is H annis MA 02601 March 4, 2013
required for y -------- -- ...__.._._-._._._.._..--
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawinq attached separately
r r •r r r r
30
25f
31 47
ty '
V 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 123 Woodland Ave _
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
15+
Estimated depth to high ground water: 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:
USGS topo map and town GIS.
You must describey 9 9 how you established the high round water elevation:
I
Town groundwater contour map shows water below el. 20 and topo map shows property above el. 40
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 123 Woodland Ave
Property Address
Karen Hayden
Owner Owner's Name
information is Hyannis MA 02601 March 4, 2013
required for
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
(Sins-11/10 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17
RtAVE9 ,
COMMONWEALTH OF MASSACHUSETTS �.� MAR 21 2
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS rOWMOF O��
DEPARTMENT OF ENVIR
ONMENTAL PROTEC`i b'N H�,��PTrq
ONE ININTER STREET. BOSTON \iA 02108 1617) 292.5S00 S`
TRUDY COKE
eC retdn
ARGEO PAUL CELLUCCI DAVID B STRUHS
Go:encr Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
P,op"Address: !23 W AOd RVfe Name of Owne+ })� CA-2 dhry
14Y2nA/.S Address of Owner: S'ih?e
Dante of Inspection: j /S '
Name of Inspector: (Pt� PPPrrriii e nt) Ati J e-f711d ( it r-C
I am a DEP approved system inspector pursuant to Section 15.340 of Trde 5(310 CMR 15.000)
Company Name: L77.r^TP
MaXng Address: :✓3 - 0/78
Teleptwrx Numbef: D� 7 S_ 6174—
CERTIFICATION STATEMENT.
I certify that 1 have personally•inspected the sewage disposal system at this address and that the information reported below is,true. accurate
and complete as of the time of inspection. The inspection was performed based on my training,and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
_ Conditionally Passes
_ Needi Further Evaluation By the local Approving Authority
_ Fails
Inspector s S:gnature,`— Date: .Z if• 1 z�
The System Inspeclor shall submit a copy of this inspection report to the Approving Authority (Board of yealth ow.DEPlwrthrn thirty (301 days of
completing this inspection. I( the system is a shared system or has a design flow of 10.000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department otEnvironmenral Protection. The originaf should be sent tottrt
system owner and copies sent to the buyer, if applicable. and the approving authority.
NOTES AND COMMENTS
re-''Sep 9 2 /dE 1"p,10l I
SUBSURFACE SEWAGE MPOSAL SYSTM viSPECT(ON FORM-
PART A
CERT1F1CATIM(oorr-eo
property Address: I Z 3 U1oe+t�l z n
Date o(of�°" %1-5e
...,,,,.S ra�lu(ARY:
g C, or u
KSPE
Check A,
p_ SYSTBii PASSES:
failure conditions described in 310.CMR 15.303 exist- Any failure
Which ind�cetes that any
✓l have not found any information of the
criteria not evaluated are indicated below.
CO1N1 AENTS-
W-JOKALLY PASSES: to be replaced or repaired- The system.Won
g_ SYST� "section need -
vents as described in ffie'Condrtiond Pass wiY ass.
One or more system components air•as approved by the Board of Health. D ��
--_._..... �n of the replacement or rep--_- ----,---_-.-_._.,--_-- lances. if-not determined explain why
aR ins _._.._..
Describe basis o� Ad s tern inspecto����
not determined fY.N.or ND). owner or operator Ms provided the Ys or to the date of the inspection-or
Indicate yes.no,or fined is rnetd•unless the twenty(20)yews au
The septic that the tank was installed unsound,shows substantial infiltration or exfiseptic n tank
Compha^ce(attached)indicating septic tank is replaced with a complying septic tank as
the septic tank.whether rx not metal.is cracked• the existing D
is imminent. The system wig pass i^s�
fame
approved by the the Board of Health
will s i
Of high staticwater lewd observed in tem
or due to a broken•settled or u w�Pas inspection (with approval of the Board of
distribution box is due to broken or obstructed pipets)
Sewage backup or breakouton box. The system
neven distribvb
Health)• broken pipe(s)are replaced
obstruction is removed
&srbution box is levelled or replacedeel pipes)- The systernrlt�
w '
—� than fourtimes a years to broken or atrstr+rct -_
.The system required pumPirtg�- of Heatfhl:
inspection if(with approval of the Board
broke,Pipe(s)are replaced
obstruction is removed
Page 2 of I I
. SU85URFACE SEWAGE DISPOSAL SYSTEM�pE�ION
FORM
PART A
CERI IRCATION(con*-ed)
2� w'�'d Isna
pvop,,tV Address- h
Owr-N: �zU� od
D�of /r/ REQUIRED BY (F{E BOARD OF liv to protect the
b the Board of Health in order to determine if the system is failing
C. FttRTtl6t EVALUATION
iie further evaluation Y THAT THE SYSTEM
JA+ /� Cations exist which re0 nNro nt WI{310 CU t5 3111�)
�bGe health.safety and the A ilfE ptfgl)CROIIEALTK AND SAFETY AND TIfE�WgUt�llMf3"Q=
PASS UNIf55 BOARD OF HfJ►LTN RO JEgNFS fM ACCO
1) SYSTEM VWN. G W A MAN �LpROIKT
fS NOT FUNCT
IS within 50 feet oi surface water wetland or a saft marsh
C eSSD
ool or pnvY within 50 feet of a_bordering vegetated
Cesspool or privy ts
IF AKV)DETERM IES TMAT THE SYSTEM 15
DF AND PUBLIC WATERS� Eil:
SYSTEM WILL FAIL
S BOARD
T pR TEC(S THENPt1Bl1C A�T?I ANO SAFETY
�ICTIONfNG W system ISASI and the SAS is within 100 feet
of a surface Water supply°f
a septic tank end sod absorption
i of a,public water suDPh wed'
The system h� Water suPplY- system and the SAS.is witltim a Zone vote water supply well
_ tributary to a surface d sod absorption sys SAS is w tW"50 feet oft u teat or more from a
The
s�ernn hhu s ses�`tam and soil absorption system and t!►e 1 O0 feet but 5��nds indicates that the
The sys on tam and the SAS is less than
The
tem has a Septictank and soi a womb er a'Aysis for coliform bacteria and vof we agarae o9en is equal to or{ass
The sys wed.unless
a wed and the presence of ammofwn nitro9env
private Water supPnl ftom that facility iity x'm+atiori not
wed is free from
��to deteeirtane distance�—(apDro
than 5 Ppm-
31 OTHER
1
Page 3 of I I
SYSTEM INSPECTION FORM
. SUBSURFACE SEWAGE pl�A
CERTIF1CAT10>'1 tcontin�
d h ry
pate at M,tpect,,=JIAJs too
-No to each of the following=
p_ SYSTEM FAILS' -Yes'or exist as d, to Correct the ta0ure.
indicate either ore of the following falure c�ducontected to determine w att will be necessary
a basis for this
Y that one or m
f havr determined below- The Board of Health should
determination is identified _
nt r . do,*ge an overloaded or�Ia99ed
SASar•casspOol- - - - -
Yes Nio irrroicrstY eel SAS or
Backup O+—*aJe surface waters due to an overloaded or clogged
ponding of effluent to the surface of the ground or
Discharge or
cesspool- ed SAS or cesspool-'
_. - i^_the dstribution box about outlet invert due to an overloaded or do99
--- -.... _.... . a ---- --- - -- ----------------------- -- - — titan V2-daV ftvL-- - ---- .._._._.. __....--------------
esspool is less then 6-below invert or available volume 1s terms
liquid depth in c ed or obstructed prpe(sl-
n more than 4 times in•the last year NOT due to do99
Required pumpi 9
Number of times pumped groundwater elevation-
stem.cesspool or privy is below the high
ortion of the Soil Absorpt+o^SY ace water supply-
Any
_ P water supply or tributary to a surf
Any OOff-n°f a cesspool or privy is within 100 feet of a surface
_ ic-within a Zone 1 of a public well.
Any Portion of a cesspool or Privy well.
'— is within 50 feet of a private water supply
n of.a cesspool or pnW Private water supply wen with no
Any P°roO ester than 50 feet from a
or privy is less than 100 feet but fir c of wen water analysis for
AnY porpwt of a cesspoolwell has been analyzed to be acceptable.nitro attach oPY
acceptable water quakty
analysis. If the amnia rrtro9e+r and nitrate nitrogen.
-cofiform bacteria.volatile orgar>;ecornp°u^
E. LARGE SYSTEM FAILS: of the following:
either Yes-or'No: to each aria above:
on to the criteria You must f1onen�t�apply to large systems in addrti s tern is a significant threat to pcbL
flow of 10.000 go or greater(Large System)and the ys
serves a facility with a design ore of the following conditions exist:
The system because one or m
health and safety and the environment
the system is within 400 feet of a surface drinking water supply
Yes No _
_ ereuppiY -- .
ithin 200 feetof ea Zone It of a Pvalic
the system rs-w
he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPAI M a mapped
t Y tonal
water supply welt) Please consult the local tag
The owner m operator of any
such system shall upgrade the system in accordance wRh 310 CMR 15.304121-
office of the Dep
artment for further information.
•
- A W 11
SUBSURACE SEWAGE DISPOSAL SYSTEM WSPECTbH FORM
F
PART B
CHECKLIST
Pr�ty Adocas: i
�AaUdh ry
Dal of "_ �Il�oa
w;n have been done 'Yes" a"No' as to each.01 the following:
You must indicate either
Check it the following
n information was provided by tfie owner.occ�Pant,or Board of Health_
Yes Noasa1llow
pumping tam basbwrxwc«�
ufpcatj,"It two woo"as�d t)ra� em recently or as Part of this
r None of tha syctem coal' n.
— rates during that period.
'Large volumes of water have not been
introduced into the s
inspection..
As built plans have been obtained and examined• Note it they are not available with NIA.
The faality or dwelling was inspected for signs. s
!� receive non-sanitary or industiw waste flow_
The system does not
The site was inspected for signs of breakout.
nests.excluding the Sol Absorption System•have been located on the site.
All system compo red for condition of baffles
nholes.were uncovered,opened•and the interior of the septic tank was inspected
The septic tank depth of liquid.depth of sludge.depth of scum_
✓ _ dimensions.deP been determined based on:-
or tees,material of construction.Absorption System orrthe'site has
The size and location of the Sal
Existing information.For example.
plan at B.O.H_ unacceptable)
— of the failure criteria related to Part C is at issue,aPpro>n*nation of stance is
Determined in the field(if any
(15.302(3)(b)1 f
zt,if different from owoar)'axe<e Pr°�°dad
yirtb infnunaboao^
_ The facrhtY owner land-
SubSurface Disposal Systems-
.
IO
SUBSURFACE SEWAGE DISPOSAL SYSTBi1 fNSpECTN FORM
PART C
SYSTEM 06"ORMATION.
y Address: ./23 W fz A
Data,N! ': 3/1 /00 on wNS
Row coy►
— 0 y-p.d-lbedroom-
erns(design)--- Number of bedroom(actual)—`L'
Number of be�oo
Total DESIGN flow—_—
of current residents:Q
Number er(Yes or nol:_W If yes. ,p"ata.inspecti0ntr0gd
Garbage grand ate system) no):
Laundry(separate tem) (Yes or
c
Laundry system inspeted (Yes or no)
Seasonal use(yes of no)'A02 Year
Water di 's usage(gpd)
meter readings.if available past two Y .
Sump Pump(yeS or"Y,__gA ofk
- - date of occxrpancY� _._.—_ .......... - -- - -
COMMERCIA
Type of estabGshRie d (B ed on 15.203)
Design flow:
Basis of design flow
Gmase trap Present:lYei or no)— _
�al Waste Holding Tank Present:(Yes no)—
IndNon-sanitary wane discharged to the Trt1e 5 system:(Yt5 Of no)_
water meter reados• available
Last date of occupancy:_
OTHER:(pescribel GENERAL INFORMATION
Last date of oceupanCr-___
pUUMG RECORDS and source of information: Un knOWn
as Pan of gallons
or no)
System,
if yes.voiuma pumped:
Reason for punn*ong:
TYPE OF SYSTEM on bo><lsoa absorption system
f� Saptic tankl6st N ti
Site cesspool
Overflow cesspool
PnvY es or no) (if Yt5•attach PCeV1Ous inspection records,if any)
�— Shared system(Y to date operation and maintenance contract
IIA Technology etc.Attach copy of up
COPY of DEP Approval
• —� Tight'Tank �—
. r-ep-
Other
AppRD7(IHC/►TE AGE of ail components,date instal
known)-and fO�6°af•�errnabon. -'
Sewage odors detected when'arriving at the.site:(Yes or no) �
SUBSI)RFAC£SEWAGE D
SYS-nM�nt)M FORM
MPOSAL
PART C.
SYST>PA WIFMWTION
Owr►cr w•�...._ _.. Ace ,
Darts at uzp=c""
(fPSEO"ocalte.on she �)
� r
Deptfr below grade- cast iron PVC_other(explain,
Material of coitswc�6,n'
D;s�rrce from private water supply`/ or suction line
ly �--
Jr a of laalra9e•retc-)
Diameter�_ ,venting,evident
Comments:(condition of joints
SEP'Tx TAMIC'_
pocate on site plan)
to Polye*Vlene_tnerZeic�tain
Depth below fie_-d - metal -fib-glass Material of construction'=oncrete_ (yesMo)
If tank is pmteL list age _ is s9e confirmed by
Cem"Ca(e of ComoanCe
O
Drrnenf1om- r Z6�
Sludge ,, : of sludge� a to bottom of wtdet let or baffle:_
Distance_fratr top of '41
Scum tom'—of m to top of outlet tee or baffle: L
Distanca born top to bottom of outlet tee
or baffler IO"
Distance from bottom of scum r
were detecnrined sU.-tur-t i-tegrit .
Mow dirrwaSIOM level in relation to outlet invert.
Cornrtwnts= eonerition of"at and outlet tees or baffles.�pth of fi�tid , -
o �'
tion for.prtmPir►9• k =
(recorra+��. etc-)
tviderKc °'
pocate on site plan
Depth below 9r1' — concrete_rnetal—Fiberglass _Polyethylene—oiher(exPlas<',
Material of cormV+C6W-
DrmIS1Orrs:
Scum thickness-_— of wider tee or baffle—_
Distance from top of smm to top
Distance from bottom of scum to bottom of outlet tee or baffle:__
Date of last p+trnpin9' to outlet invert.structural
integrity.
Comment? On for puffing,condition of inlet and outlet tees or baffles,depth ol6arrid level in relation
(reconw-- ab etc.,
evidence of leakage.
P�oc 7 0l 11
SU65l1RFACE SEWAGE D
SYSTM�M FORM
PART C
SYS.MM W**MAT M(cMWn—O
Peopesty Add
insPx�-ar
G 7�� T must be pumped),nor to.or et time of.
--nGHi OR HOEDBIl
(locate on site Plan)
Depth belowgrade:__ concrete_metal_Fiberglass Polyethylene_other(enpla•nl
_
Material of construction:_
pemensons gallons
CaPDCSY'---- gallonsiday
Design fiow:----- ---
Alarm vest Alarm in working order:Yes Na
Date of previou P
Coen ants:
(cot,ditio�n of inlet tee.condition of alarm and float switches,etc.
UTtOM BOX
(locate on site plan)
Depth"of 6gdid level above outlet
Comments: land
of solids carryover,evident
e of leakage into or out of box.etc.)
(rote if lewd and distribution is equal•
10.
f CHAME><l:
(locate on site Plan)
pumps in working order-.(Yes or No)
Alarms in working order(Yes of No) •
Comments: of
of pumps and apportena' etc.)
(note condition of pump chamber.
SUB SuRFACE SEWAGE DISPOSAL SYSn"WSPECTION FORM
PART C
SYSUM vM)WAATION fewitinuem
property Address: IZ3 we;�4 1-24
owner- eh oad h ry .
Daft Of
SOIL�� c_ySTEW(SAS): red.location rnsy be cpproxi"I by non-intrusive methods'
Voss ,:excavation not requi
(locate on site plan.if
B not located. explain:
Type: prCC 2St
leaching Pits.
number:
leaching chambers.numb,►—
leaching galleries.number:
{,aching trenches.number,1en9th:--- —
leaching fields.t MdW.dunensions.
overflow cesspool.number._— '
Name of TechrwlogY:
Co u sue•condition of vegetation.etc-)
(note condition of so damp
il•signs of hydreuGc ipdure.level of pa ng•
t .
2
�ESSpOOLS
(bcate on site p n)
Number and.eonfigucation:
Depth top of liquid to inlet invert:
Depth of solids Ester:
Depth of 9cUm�Y�=
Dimensions of cesspool=
Materials of eonsttvction=
ir►dcation of groundwater: of Cori)
inflow(cesspool must be pump part
(n bon of son.signs of hydraulic faiComments: lure.level of pori6rr9•
con6tion et,vegeeation.etc_)
ate
PI
site plan) _
((Deare Dimensions'
Materials of construction:
Depth of solids•
Comments: ition of vegetation:etc.)
(note condition of soil.signs of hydraulic failure.feud of Vor�ng,cord
SUBSURFACE SEWAGE DISPOSAL
SYSTEM YdSPECT101�FORM
PART
SYSTEM NFORIAAMN(cononueM
Peap.M Addrams:
sM-FC{OF SEWAGE DISPOSAL SYSTEM: s of benchmarks
include ties to at least two permanent reference Isndn►ark supply comes into house)
locate an wells within 100'(Locate where public water'
r Z
� A
29
/lZ- Z3"` B2-30r
A3 - 3'3 23- 34
�t A4-- 3 i' gt-4-7
� M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTW"FOW
PART
SYSTM ORWMATM(conti..A
pmpertyAddiess:123 wood/a»�
owner--
- GhdUc�hrY
MRCS Report name
Sea Type_
Typical dePth to groundwater
USGS Date wsbsite visaed
Observation Wells checked Moderate--�Deep -
Groundwater depth: Shallow
SITE EXAM Slope - lime,
Surface water /fie, .
Check Cellar dry
Shallow wells
...._ pth to--- ------- -- G' -eat E-- .. ...... ....: .. ... . ........_. _..._._. .. __..... ....---. .. ......._...
Estimated Deoh�tidvrater
please irhdicate all the methods used to determine Kgh Groundwater Bevation:
Obtained from Design Plans on record
Observed.Site(Abutting property,observation We.basemeot sump etc
DW tarnfs—d from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
ter*ed local excavators.installers '
used 1lSGS Data
established the High Groundwater Elevation.(M mt be completed II
Describe how you
rim. de Ej
geovnj W2I-er C-jcv- Zo ,er .>72ps
� �� Page 11of11
}
r
Commonwealth of Massachusetts
Executive Office of Environmental Affairs Fe 2 o J
Department of �� 8 1%
Environmental Protection 4
Wllllam F.Weld
Gammon R >4
Trudy Coxe "�^-�.�.,_•--""`
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I PART A
CERTIF CATION
Property Address: Address of Owner:
Date of Inspection: (If different)
Name of Inspector:-
Company Name, Address and Telephone Number:
-aa-2, A,evz l�y
CERTIFICATION STATEMENT
I certify:that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
� .Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
i
Inspector's Signature Date: c
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and.the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sere tv tn(• system owner ano copies sent to the buyer, if applicable and the appro%ins au!hori;y.
INSPECTION SUMMARY:
Check A. B,C,or D:
Aj SYSTEM PASSES:
v I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria.not evaluated are indicated below.
e) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N,:or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The,septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
i
(revised 6125195)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292.5500
~J Ptinted on Reryeled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: WOOD�-A« O;Av L 1= k
Owner: YA.\L-e�-
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(wish approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQU
IRED 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 the
public health, safety and the environment.
1) SYSTEM,WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN,A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
.2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENV IR01siENT.
_ 1he wstern_ha,. a septic tank anu son ausurptiun system anu is within i0v foci io a suiaCc 'vac; supp:) o.tributart" to-a
surface Hater supply.
_ The system W- a septic tank and coil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply.well.
The system has a septic tank and soi; absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
PPM
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for.this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. `
(revised 8/15/95) 2
SUf3SU.RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: WC70,01 -Wvb AAJ7e- 6!- • l-����'..v w
Owner: 1('Y\--,\\-e
Date of Inspection:
a�
DJ SYSTEM FAILS (continued):
Static.,liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
f' Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow,
r4 Required pumping more than 4 times in the Iasi year NOT due to clogged or obstructed pipe(s). "
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
I"f Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
I�
An portion of a cesspool or privy is within 50 feet of a private water supply well.)
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
a
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flo%%:.of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions he
the system is within 400 feet of a surface drinking water supply
the'system i, 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 It of a
public water supply well'
The owner or operator of.any such system shall
easelring the consult thetem localnreg'tona�office into full compliance of the Departmenttforhfurther information.tment program
requirements of 314,CMR 5.00 and 6.00.
3
(revised 8/15/95)
I
r:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: '('y\A-"✓-
Dale of Inspection:.
Check if thefollowing have been done:
✓/Pumping information was requested of the owner, occupant, and Board of Health.
None of.the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
✓As built plans have been obtained and examined. Note if they are not available with N/A.
1/The:facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
JThe site was inspected for signs of breakout.
_,L�All system components, excluding the Soil Absorption System, have been located on the site.
I
e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tee$,.material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
'!The size`and location of the Soil Absorption System on the site has been determined based on existing information or
�a proaimated by non-intrusive methods.
+� she facili:.) c•: .d occopan:u, if c!:4vro^t f-o^•. ov.ne,: were provided with information on the proper maintenance of Sub-
Surface.Disposal System.
Irevised 6/15/M 4 �'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: L-►VLZD AQe-. CiC
Owner: VK ` i-
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: f330 allons
.Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):-Z?
Laundry connected to system (yes or no):-Y—
Seasonal use (yes or no):-L-(
Water meter readings; if available:
Last date of occupanc�: �c-'�:—( `t wk-e,
COMMERCIAUINDUSTRIAI: f
Type of establishment: �J
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system:(yes or no)_
Watermeter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupant)
GENERAL INFORMATION
PUMPING RECORDS and source of information: ,
System pumped as pan of inspection: (yes or no)
If yes, volume pgmnr•d pallow
Reason for pumping: --A n,
TYPE OJSYSTEM
V Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 7��5
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: I a 3 Ulf(>Ub L- c--0 A-v-e--
Owner: ew.��
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:'
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ t(
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 lees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of'leakage, etc.) CX)i S c_
of
e`
GREASE TRAP:
(locate on site plan)
Depth below grade:`
Material of construction: _concrete _metal _FRP_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from hottom no cryin, If, tlhtlOm O1 MI!IP! tee M bdolw-
Comments:
(recommendation'for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
rn F
integrity, evidence:I leakage, etc.(
i
(revised 8J15/95) 6
' SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTIOWFORM
PART C
SYSTEM INFORMATION (continued)
Property Addre�js: �� wooOV 1AOv .E is i (-� cc aL:�. i '' 1 .:;C►:
Owner: f/VU,�j1e--_' 60
Date of Inspection:,
TIGHT OR HOLDINGTANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of.inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: "
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
tnote n level and diiiiiWtaul. u:.',I: La:11 U1C1, C.'idence Of leakage into Or Ut of box, etc.)
,V D C> ���' l c�h �
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: � 3 �J-,`( 1p1-hl�� y_�� = c�1�T f`1 T«��•�-c
Owner:
Date of Inspection;
SOIL.ABSORPTION .SYSTEM (SAS):
(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
leaching pits, number:
leaching chambers, number:_
leaching galleries, number: .
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOL'$e.�
(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 groundwatc:.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,.etc.)
PRIVY:
(locate on site plan)•.7.
Materials of construction: Dimensions:
Depth of solids:
,Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8125195) 8
v
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: �` ,�
Date of Inspection:,
SKETCH.OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
4;L
��' ✓
(UV✓
"4J�
DEPTH TO GROUNDWATER, `t
� 'ea`�w
Depth to groundwater:�_feet
Yv �iaw� o�
method_of determination or approximation: �iT i 0,3e- f0
. I
(revised 8/15/95)', 9
166
L"0 AT ION SEWA E PERMIT NO.
V14LLAGE
INSTA LER'S NAME AD,"ESS
BUILDER - OR OWNER
DATE P RMIT ISSUED:""
:DATE COMPLIANCE ISSUED -I\
-------------
r>
_ `r
off. 3 sz
o2
asn°ff ��
b _
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable
...........................................OF..........................................................................................
Appliration, for 11itynaut Worka Tonstrnrtion rrmi#
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
11,ot Y 10 Woodland Ave. , Ext. Hyannis , YA
............................................................•---•---...................----------- .......................................:-.-•
e¢e ------------------------------------------------------
Capricorn R `tyA` ijUSt 765 Falmouth RdtLIdt,N°Hyannis
..... ..........................................•.........---••-..........._.... ..........-•......................................................................................
(ra Steve Lebel Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.-3.......................................Expansion Attic ( ) �;rarbage Grinder ( )
'4 Other—T e of Buildingranch ..... No. of persons...................... Showers G — Cafeteria
a' Other fixtures ............................
------- -------- -.
330
W Design Flow........55...•----•--•- •-1000 gallons per person gel day. Tot �l�i�y��iow........................................ glpns.
WSeptic Tank—Liquid'capacity-_...--0.gallons Lengt ................ Width................ Diameter................ Deptl.....__..._.....
x Disposal Trenchl-No .................... Widtj�-�......_........... Total Length...... .t..........Total leaching area sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosin a
l �PeNdAe Engineering 11-25-81 =
Percolation Test Results Performed by..............:.......................... Date................_._.._.......__.....__..
2 a 0 12 •----•-•-- ...... . none encounte�-
`�a Test Pit No. 1_..rr........_..minutes per inch Depth of Test Pit.... ............. Depth to ground water_- _--___---_,... e
(i, Test Pit No. l.A.........minutes per inch Depth of Test PitI� A....__._.... Depth to ground water.NIA.............
....... ..................... --•-----• ..-._...........................................................................................
O Description of Soil.......... ? Y loam & yOpsoll -------------------- •----•------
x 2 - i6 ------Nieclium....e11•ow... and---------------------
----.......i� ---_..-I•�•r......med: wlZi e sand/traces o f---gr�:ve11my-_-wait ---rt-- 12
------------------------------------------------•-------------------------------------....----------------------------------------------------------------------------.................................
V Nature of Repairs or Alterations—Answer when applicable..............................................................................................
----------------------------•--•-----------------------------------------------.......-----•---•--•--•-••--••-------------------......•-----•--------------.........---------------------..............
Agreement
The undersigned agrees to in tall the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of rqITO 5 of.th tate Sanitar Co4e— The undersi ed further agrees not to place the system in
operation t' a C ficate o omplianc as en issu by e bon
of health.
i ne ........- Pres . 75�8?
te
lication Approve B _.. ........�rr �. .............. 2 �5 a&xc
PP PP Y -•••--•• --
Date
Application Disapproved for the following reasons:..........................----------------------------------•------------------•---............................
......-•--•...........................•--•-------------------...••-------•-------•-•---•------------.......----•--------------------------------------------------------- .........................
Date
Permit.No..........................:....•••------•---...--•••-.... Issued....................................................... .
Date
NO........................ .............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Towm Barnstable
......................................OF..........................................................................................
Allpfiration for Disposal Works Tomitrurtion rrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System r:
To 10 IjVoodland kve. , Ext. Hyannis , 14A
------------- .................
Ca ricorn RLLaIt y.A�Trust............................................
7�5Falmouth RowdtgNoHyannis
p
................................................................................................. ..................................................................................................
Steve Lebel Owner Address
.................................................................................................. ..................................................................................................
Installer Address
Type of Building 3 Size Lot.............................Sq. feet
U
Dwelling—No. of Bedroom rs..a.....nc.h...................................Expansion Attic garbage Grinder
Other—Type of Building ............................ No. of persons__.._____.__________________ Showers ( ) — Cafeteria
Oth< ' fixt -------------------------------------------------------------------- ... ....................................-
� ures-----------------------------------
'5
W Design Flow________________________j.0rC)0..gallons per persT gox day. Tot 4j iliV„flow_.__._._____.____.__________._._______._5_gEllons.
9 Septic Tank—Liquid capacity.............gallons Length___._...____.___. Width________________ Diameter._.._____._____. Depth___________.._..
Disposal Trench—No. .................... Widt4.................. Total Length......6-1......... Total leaching area----266.......sq. f t.
Seepage Pit No..................... Diameter_._...__._...._...._ Depth below inlet__________...._..__. Total leaching area..................sq. ft.
Z Other Distribution box DosinEp� 6d�e Engineering 11-25-81
Percolation Test Res 2ltso Performed by_________________________________________124------------------------- Date..............nonle---enaounte
Test Pit No. .........In inutes per inch Depth of Test Piq4^............ Depth to ground water..N/A.............. e
rd
Test Pit No. .`_.______________minutes per inch Depth of Test Pit.................... Depth to ground water_-___.____________.____.
1 0.+.-..;;.;---24----------I-OaM---&....topS"O±a:----------------------------*---------*........*--------------"--------------------------
0 Description of Soil_._.______'4A ------M6-d!Um--7ff1-1-0W--sand------------------------------------------------------------------------------
...................................
U ------med-0-----wh-ite...sand/t-rares--- a t--- 12'
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................................................................................................................................................................................................... ..
Agreement:
T under ed a to install the aforedescribed Individual Sewage Disposal System in accordance with
y
"men,t er ed a t
^h i .
e 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
P7. i. r sate of
0 ion it a Cer te of Compliance has been issued by the board of health.
je.�� Pres'. 7/5/84
vri n—te d... ------(4W-4j ........................................... ......... ........
Applicati6nApproved By.. =.......................................................... ........................................
Date
Application Disappr6ved for the followinq'reasons:....................................................................................i...........................
........................................................................................................................................................................................................
Date
PermitNo._'i................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
.......I............................OF..........I..........................................................................
U'pWrtifiratr of (gompliaurr
THIS.IS TO CERTIFY T th eLti S evehat eIn evual Sewage Disposal System constructed or Repaired
by
y------------------------------------------------ .... .......................................................................................................................................
Lot 00 Woodland iive. , Ext. Installer Hyannis, KA
at............................................7111*-""*""""*,,11*11--l'I'lIll""""I----111.......................................................................................................
has been installed in accordance with the provisions of TITLE 5�of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated_...._..._..._._....__......_.-._:..._....____..
HE IS WMCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
Z:Z
SYST L,.FUNj:TIO SATISFACTORY.
DATE.....................). _9.1........................... Inspector.... awlj�
.............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
.........................................OF.....................................................................................
No......................... FEE.__.....................
ytrurtion Vrrmit
IIN.- S eye Le
Permissionis 11*bWaoidbL'1d.. .........................................................................................................
to Constrft or Repair any Individual Sewage Disposal SAslem
(o YarmiS, MA
at No..................................... .................................... ....
------------------------------------------------------
ee t
as show ......................................
h non-t4e application for Disposal IA7ofks Constrtietii)n—N No.' ated....,
................................................................................
Board of Health
DATE.............. ..............................f...................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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li1GH GROUND-WA1ER LEVEL COMPUTAT1UN r
t1 .
Si to' Loca,t ion Lot No
I y:
d.Qw ,
Owrier F nAje-c-_ Address 7 F���,Qu,-tr 9i
Contractor: t' Address
Notes.
f
4
STEP 1 Measure depth to water table
b�
.�' to nearest 1/10 f t. �• ���/��� t y{y{y{777
' 9
{ date '
--------— — __ � i ,
STEP` ;2 Using Water-Level Range Zone'
and' Index 'Well Map Aocate
_� T.
twri srte, and. determine. .
A + t
23'
A) Apprbpriat.e index we,l.l w �
t
B) Water-level range ` s r
d zone u
STEP 3 Usiri� monthly report"Current
,r Water Resources Coridi t ions'r
determine current. depth to •8 122,>2. ' : j
/ ` �•
water: level for.: wrnd'ex well
G 5 . . mo Y r
:STEP, 4 Using Tablc of Water-level i
` Adjustments for ' i.ndex well
t;STEP 2-Al current depth too ?'
water leycl. for index well
J'
(STEP 3.) , and water .
zone zone: (STEP 2B) determine:- x `
water-level ��adjustment . . . . .
. .
STEP.' S. Eetirlate depth to high, wat:er
by subtracting the 'wat.er
r,
level adjustment (STEP a
f turn measured depth to water
level at site (STEP ..1) .. . . . . . r . . . . - t '
t{ + 1��}•a f t -�;s � --- -•� 4 * h�! k � ix '$'t t`3 i s s i� 'a,