HomeMy WebLinkAbout0234 ARROWHEAD DRIVE - Health 234 ArrowheadDrive
Hyannis P,
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COMMONWEALTH OF MASSACHUSETTS I
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTEC IO
RECEIVED
OCT 2 7 2003
O TOWN OF BARNSTABLE.
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 234 Arrowhead Drive MAP
Hyannis PARCEL '
Owner's Name: Michael Martir
Owner's Address: SLOT :
Date of Inspection:
Name of Inspector:(please print) W i ) ) i am _ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number:- ( soB) 77 s-877'6
CERTIFICATION STATEMENT
1 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:
--t "asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
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Inspector's Signature: � , ,� ,►-� �6� Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or •.
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP..The original should be seat 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. '
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Title 5 inspection Form 6/15/2000 page 1
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Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address:_ 234 Arrowhead Drive
Hyannis
Owner. MTrhapl MArfir _
Date of Inspection; 6 U
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy em Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. S stem Conditionally Passes:
ne 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 y s,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, khibits.substantial infiltration or exfrltration or tank failure is imminent.System will pass inspection if the
existing t2 nk is replaced with a complying septic tank as approved by the Board of Health.
*A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicaten that the tank is less than 20 years old is available.
ND expl in:
servation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approva of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND expla :
Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspe tion if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed of
ND expla :
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner:
Date of Inspection: •-G .=5
D. S lem Failure Criteria applicable to all systems:
You m t indicate"yes"or"no"to each of the following for all inspections:
Yes IN
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'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface
water supply.
Any portion of.a cesspool or privy is within a Zone I of a.public well.
_ 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.]
(Yes/No)The system fails. 1 have determined that one or more ofthe 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 a considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You ust indicate either"yes"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to the criteria above)
yes o
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—1WPA)or a mapped
Zone 11 of a public water supply well
If you ave answered"yes"to any question in Section E the system is comidered a significant threat,or answered
"yes"i Section D above the large system has failed.The cmma or operator of any large system considered a
signific nt 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 3 of l 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner: Mi nhael . Marti r
Date of inspection: 4>
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 iling 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
Z. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sys em is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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 coliforrri
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 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 234 Arrowhead Drive
Hyannis 3
Owner: Michael Martir
Date of Inspection: 1y1,15—u
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):.L Number of bedrooms(actual): 1�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �,LS
Number of current residents: _
Does residence have a garbage grinder(yes or no): �
Is laundry on a separate sewage system(yes or no)JLa [if yes separate inspection required]
Laundry system inspected Ves or no):
Seasonal use:(yes or no): �
Water meter readings,if available(last 2 years usage(gpd)): ? °- `j
'Sump pump(yes or no). V C5`Z ay ,r6-0
Last date of occupancy: /6—
COMMER IAL/INDUSTRIAL
Type of esta ishment:
Design flow lbased on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap resent(yes or no):_
Industrial aste holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):_
Water m er readings,if available:
Last dat of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: A c, b J
Was system pumped as part of the inspection(yes or no):�V
If yes,volume pumped:as -* allons•=How was quantity pumped determined?
Reason for pumping:
TYP OF SYSTEM
OF
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 contact(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:
i plc/ .o S A a o/ !
Were sewage odors detected when arriving at the site(yes or no):tL U
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ri PART B
CHECKLIST
Property Address: 234 Arrowhead Drive
Hyannis
Owner: Michael Martin.
Date of Inspection: - -v S-a C>
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 7
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 7
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?
TIC 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)]
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Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner: Michael Martir
Date of lospec1l0n:4--fj-Z,!;--6
TIGHT or WING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below de:
Material of con traction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: Rations/day
Alarm present( es or no):
Alarm level: Alarm in working order(yes or no):
Date of last pu ping:
Comments(con ition of alarm and float switches,etc.):
DISTRIBUTION BOX:Zorprescrit must be opened)(locate on site plan) '
Depth of liquid level above outlet invert: l
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: (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.):
. s
]'age 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Drive _
-Hyannis
Owner: r
Dale of Inspection: A0
BUILD G SEWER(locate on site plan)
Depth bel w grade:
Materials f construction:_cast iron _40 PVC_other(explain):-
Distance oni private water supply well or suction line:
Comment (on condition o.f joints,venting,evidence of leakage,etc.):
SE
PTIC TANK:Zoocale on site plan)
Depth below grade:
Material of construction: /oncrctc metal_fiberglass_polyethylene
_othcr(explain)_i
If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) P ,
Dimensions: G A-
Sludge depth: /-,3
Distance from top of sludge to bottom of outlet tee or baffle: _
Scum thickness: -X I I
Distance from top of scum to top of outlet tee or baffle:.
Distance from bottom of scum to bottom of outlet tee or baffler
How were dimensions determined:_ O nw Gc,i, o"iZs
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet evidence of leakage,etc.):
s
w X T V �.-
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of eonstructi n:_concrete metal_fiberglass_polyethylene,other
(explain):
Dimensions:
Scum thickness:
Distance from top of s um.to top of outlet tee or baffle:
Distance from bottom f scum to bottom.of outlet tee or baffle:
Date of last pumping:
Comments(on pump i g reconmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet in ern,evidence of leakage,etc.): .
7
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner: Michael Martir
Date of Inspection:/a—t5—o
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or'
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner: Michael Martir
Date of Inspection: '16—/S G 3
SOIL ABSORPTION SYSTEM (SAS): t-occate on site plan,excavatiodnot required)
If SAS not located explain why:
Type
aching 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.):
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: ,y
Depth of scum layer: {f Lf
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.):
PRIM': (locate on site plan)
Materials o construction:
Dimension
Depth of so ids:
Comments ote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Drive
Hyannis
Owner. Mi rhaPl Marti r
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater '/ 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:
0 rved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: S
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
(�' S j4•j' coy Y
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TOWN OF BARNSTABLE (�k .
LOCATION 34 A2.0,Q V2LL SEWAGE # 'aQQi a61
VILLAGE ASSESSOR'S MAP & LOTZ70'�d�e�
INSTALLER'S NAME&PHONE NO. R-o b�u�SO L-. SEn c -n �-g 7 7�
SEPTIC TANK CAPACITY rQTC gn
LEACHING FACU ITY: (type) WC-i� (size) 1 +3 U
41
NO.OF BEDROOMS
BUILDER un ``"NE
PERMITDATE: 5�14Y JaUo i COMPLIANCE,DATE: 5�p)06 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet '
Private Water Supply Well,and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist.
within 300 feet of leaching facility) Feet
Furnished by
LU
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TOWN OF BARNSTABLE
,LOCATION -02Wt- SEWAGE # QQQ( -a6)
` VILLAGE Nyf11NW15 ASSESSOR'S MAP & LOTZ70—diff
INSTALLER'S NAME&PHONE NO. R-o lac u�SO t�3 SC-nfi�C S-g7 76
t '
SEPTIC TANK CAPACITY CYO-0
LEACHING FACILITY: (type) V WC Its 33 (size) i arta+30
NO. OF BEDROOMS
BUILDER
PERMIT DATE:' S qI a 0 0 o ` COMPLIANCE_DATE: 15 a(I,106 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
rl
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No. Fee 5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS �
Zipprication for Miopool braem Construction Vermtt
Application for a Permit to Construct( . )Repair( )0 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
234 Arrowhead Dr. , Hyannis Tessa Thomas
Assessor's Map/Parcel 7 ,70
nD—d,FQ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:.
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures'
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
E
Nature of Repairs or Alterations(Answer when applicable) Title leaeh system
ci gfi ng of a T)-hay and 3 precast leaab cha hors with StQnQ
all ar&in8
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Boar of •e
Signed Date
Application Approved by y _ _ Date
Application Disapproved for the following reaso s
.�
Permit No. ® Date Issued
f
v'
No //J R cam" Feet c�_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for Zioaal *pgtem Cowaruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
w. Asa3,4'sl4rgg`6ihead Dr. , Hyannis Tessa Thomas �.
.:.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. .E. Robinson Septic Service
P O , Box 1089 Centerville I _
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder
1 Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
k
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Sand
,t
' Nature of Repairs or Alterations(Answer when applicable)
Titie-b Ieachsystem con=
sisting of a -boxand ars ast !each chambers
around, t
i Date last inspected:
Agreement:
r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
'Y. Signed Date
1
Application Approved by 14
Date
Application Disapproved o the following reaso
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Thomas
>> , Certificate of Compliance
THIS IS TO CERTIFY,that the On-site.Sewage Disposal System Constructed ( ) Repaired ( X )Upgraded( )
Abandoned( )by ° E. abinsen Septl-e—Gerv$ve ,
j•'T at 12 n Arrowhead Dr. ' has been constructed in accordance
c =' with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
• Installer Designer r '
t The issuance oT thts°perrri t s al�ln?te conl;trued as a guarantee that the system will fu ion as design
YG
x Date Inspector
' ✓
4,
k. ------------ --------- ------
¢• s No. Fee
/ THE COMMONWEALTH OF MASSACHUSETTS
a PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigpogal *pgtem Congtruction Permit
PeBs&iomjs hereby granted to Construct Repair( X)Upgrade( )Abandon( )
System located at 234 Arrow-Ahead Dr. , Hyanni:5
and as described
,t i n t i0above Application' for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Tittle156nd the following local provisions or special conditions.
Provided:Cokstructio stjbe completed within three years of the date of this t.
7. Date: Approved by .
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NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERT MAMON OF SICKI(:R AND APPLICATION FOR A MSPOSAL
WORKS CONST ucnoN PERMIT DESIGNED PLANS)
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William E. Robinson.5l y cenifY that the application tir disposal works.
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consuucuon pent&sipped by me dated ��`� . concerning the
property located at 234 Arrowhead Dr. , Hyannis meets all of the
following criteria:
• The failed system is to a ledd=W dwelling only. T tme are no commercial or business .
uses assotdated with dwelling.
The soil is as CLASS I and the pereotanoxt rare is bm than or equat to 5 minus per inch
There are no within 100 feet of the proposed septic stimem —
There arc no pri walk within 150 ieet of the proposed septic quern
There is no i 1 m flow audlor chaoF in use proposed
• There are vatianoes mgntssed or needed `
The of the ptapomed &:3h y will nit be located less than five fea.above the
ntamm adjusted groundwater table elevation WiM the groundwater table using the Frimptor
method when applicablef
if the S.:3LS-will be located with 250 fat of ate;vegaacod wghnds.the bottom of the proposed
leaching f c ty►will no be located his than fautaen(141 fen above the maximum adjusted
goundwatcr table clevMn L
Please c�pltxe the follwri�
'.) Top of Ground Sntfax Etaaiiot(using GIS inW afuml
B i G.W.Elevation +1he MAX WO G.W.Adj,utmenl '---
DIFFERENCE BETWEEN A and B L —
SIGNED:_A DATE: /
(Stretch proposed plan of sys=on batdcj_
,r health folder.,rn
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\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P7HEAL7THDEPT.
2001
S i titsLE
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 234 Arrowhead Dr.
Hyannis
Owner's Name: Tessa Thomas
Owner's Address: same
Date of Inspection:—f —�
Name of Inspector:(please print) W i 11 i am E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant�toSec n 15340 of Title 5(310 CMR 15.000� The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 116,, 1 - Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth',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 apprommi.g
authority.
Notes and Comments
"e,
****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 6/152000 page 1
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 234 Arrowhead Dr.
Hyannis
Owner: - "Thomas
Date of Inspection: `•off`LQ
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S�ystee asses:
have not found an information which indicates that an of the failure criteria described in 310 CMR
lh y y
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
i System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
r aired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
swer yes,no or not determined(Y,N,ND)in the for the following statements.If"not.determined"please
e plain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
sound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
xisting 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 obstswed 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:
Page 3 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 234 Arrowhead Dr.
Hyannis
Owner: Thomas
Date of Inspection: "®
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 fa ing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
ystem is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2. Syst m will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system i functioning in a manner that protects the public health,safety and environment:
_ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.of'a
surf ce water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
rivate water supply well". Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
ba teria and volatile organic compounds indicates that the well is free from pollution from that facility and
the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fail a criteria are triggered.A copy of the analysis must be attached to this form.
3. O er.
a
3
Page 4 of I 1 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 234 Arrowhead Dr.
Hyannis
Owner: Thomas
Date of Inspection:
D. S stem Failure Criteria applicable to all systems:.
Your Est indicate"yes"or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume.is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 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.]
(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.
i
E. Me Systems:
To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You ust indicate either"yes"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary.to a sm1hce drinking water supply
i
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 1I of a public water supply well .
If y u have answered"yes"to any question in section E the system is considered a significant threat,or answered
"ye "in Section D above the large system has failed.The owner or operator of arty Large system considered a
sig ificant 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.
4
I '
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address?3 4 Arrowhead Dr.
Hyannis
Owner: Thomas
Date of Inspection:{� �--d Z
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
i
Yes 0
r/ 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?
_ _..4,Xave 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
V — Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
_L/I._ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_�_ facility owner and occupants if different from owner)provided with information on the proper
Was the f ry ( p
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Ye;/ no .
_ Existing information.Foi 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:234 Arrowhead Dr.
Hyannis
Owner: Thomas
Date of Inspection: O -
FLOW CONDITIONS
RESIDENTIAL y�
Number of bedrooms(design):_-/ Number of bedrooms(actual): L�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: 3.
Does residence have a garbage grinder(yes or no): i
Is laundry on a separate sewage system(yes or no):,&()[if yes separate inspection required]
Laundry system inspected(yes or no): 0
Seasonal use:(yes or no):/A--v
Water meter readings,if available(last 2 years usage(gpd)). 2 0 0 0 9 0'.�0.0 0 gal
Sump pump(yes or no): IL 0 , gal:
Last date of occupancy: —0 �
CO MERCIAL/INDUSTRIAL
Type f establishment:
Desig flow(based on 310 CMR 15.203): gpd
Basis o design flow(seats/persons/sgft,etc.):
Grease ap present(yes or:no):_
Indus' al waste holding tank present(yes or no):
Non-s itary waste discharged to the Title 5 system(yes or no):
Wat meter readings,if available:
Las date of occupancy/use:
O HER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: �✓
Was system pumped asp of the inspection(yes or no):
If yes,volume pumped: allorps--How wa uanti umped determined?
Reason for pumping: o
TYyOF 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 kno. n)and source of informatio
Were sewage odors detected when arriving at the site(yes or no):
i
6
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: 234 Arrowhead Dr.
Hyannis
Owner: Thomas
Date of Inspection: —8
ILDING SEWER(locate on site plan)
De below grade:
Mat rials of construction:_cast iron _40 PVC_other(explain):
Dis nce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
0
SEPTIC TANK: locate on site plan)
1
Depth below grade:�_
Material of construction:_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top ofsLidge to bottom of outlet tee or-baffle: _
Scum thickness:
Distance from top of scum to top of outlet tee or baffler 1
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: C
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to.outlet invert,evide ce of le. 'age,et,4:
GR SE TRAP:_(locate on site plan)
Depth low grade:
Material f construction:_concrete_metal_fiberglass polyethylene_other
I (explain)
Dimensi ns:
Scum thi kness:
Distance from top of scum to top of outlet tee or baffle:
Distance om bottom of scum to bottom of outlet tee or baffle:
Date of 1 t pumping:
Commen s(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):
7
f
Page 8 of l I '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Dr.
Hyannis
Owner: Thomas -
Date of Inspection: _0-
TI' T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth elow grade:
Materi 1 of construction: concrete metal fiberglass polyethylene other(explain):
Dime sions:
Capa ity: gallons
Desi n Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
Date of last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ti
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 HAMBER: (locate on site plan)
Pumps• working order(yes or no):
Alarms in working order(yes or no):
Comm nts(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Dr..
Hyannis
Owner: Thomas
Date of Inspection: —O�
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
Z leaching chambers,number:
leaching galleries,number: e
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:: _ M
innovative/alternative system Type/name of technology: y
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): 3 111 ' ?A 61/ £ %, I s -d
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet ' vert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: 1
Materials of construction:
� t
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Mat ials of construction:
Di ensions:
De th of solids:
C ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 234 Arrowhead Dr.
Hyannis -
Owner: Thomas
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
� 1
31 ,
w
/V
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: 234 Arrowhead Dr.
Hyannis
Owner. Thomas
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
gbtained from system design plans on record-If checked,date of design plan reviewed:
e/ served site(abutting property/observation hole within 150 feet of SAS)_
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe ow you established tL�gh ground water elevation:
t �y
_ 11
�¢ TOWN OF BARNSTABLE
t+.00ATION 3 7 WOW{IF1-0 cDVAV'e— SEWAGE # CIS-y03
VILLAGE_ `-14 4ml`(u ASSESSOR'S MAP & LOT -2 70-Q$of
INSTALLER'S NAME & PHONE NO. �( Cr
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)Z74§�%U-TV-Kt VS (size) �X -.0
NO. OF BEDROOMS. PRIVATE WELL O UBLIC WAT�/-ER
BUILDER OR OWNER `i Np
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
(b Q b
N
49
vi
J
i
ASSESSORS MAP NO• ��U
PARCEL NO. D
No.... `_- FizR..13e)...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diinvasal lVurk.6 C owitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair / an Individual Sewage Disposal
System at:
Locat' n-Address o ',-n� or Lot No.
y Y,c1�- e rt�n, 61
............ - ---•-------
,�{{ Owner Addres�f/� c
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............-------------------------------Expansion Attic ( ) Garbage Grinder ( )
a 'Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures ------------------------------- ---
qoW Design Flow.......' _.. �.... .. gallons per person per day. Total dai flow_______ _____________________
g ''ii g P P P Y jY -----------------------------------gallons.
WSeptic Tank—Liquid c pcity/�Qf1-galIons �ength.../0_..... Width..ea.......... Diameter................ Depth................
x Disposal Trench— NoA_*_ZV*. G- Width...... ............ Total Length--:90_..._.._ Total leaching area--------------------sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 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........................
a ...........................................................•------------•-........----------•••••••..........................................................
0 Description of Soil........................................................................................................................................................................
x
U ---••-•---•-------------•••--------•-••-••••-•-•-•-••-•••------------------•------•-----------•------------------------------------------•-----------------------------•-•--•-••--•••------------•------
W --------------- ------------------------------------------------------------------•--•-•••---------•------------------- . ...............................................................
UNature of Repairs or Alterations—Answer when applicable.. w 1:�._..,..5� .. 7 '��J�.�..Z...� ..
l�S.a ` ------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place.the
system in operation until a Certificate of Com liance has been ' the boa ealth.
Signed ....... ....... ... ....... ..... .... .... ...... ................................ ...�.`.........................
Dace
Application.Approved By ......tee-m.,... ................................. ................................................. ..... ...�.�(...:.9 ..
Date
Application Disapproved for the following reasons: ........................................................................................................................................
..............................................................................................................................................................................................................
Permit No. .....7,J-......"..Yaz....................... Issued ................-.................
..................................
Date
Dare
t s
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
- TOWN OF BARNSTABLE
Applirativit for Dita}I11 ial Wurkii Tomitrnrtiou Frrmit
Application is hereby made fora Permit to Construct ( ) or Repair 1>41 an Individual Sewage Disposal
System at:
................ 1A l l�ec�Q•_�r_11a r
Loeatipn-Address 0 'n or Lot No.
Owner Addres
L
Installer Address
Type 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
a' Other fixtures •---•------------------------- --
W Design Flow........ ... .......... .....gallons per person per day. Total day flow..... :��U.-..........-....__....--gallons.
WSeptic Tank—Liquid capacity/ 0UgalIons Length.../0..... Width--�.......... Diameter................ Depth................
x Disposal Trench—No._.P:?/,-�. Width...../_.-.---..... Total Length.-�Q_....---. Total leaching area....................sq. ft.
Seepage Pit No.............:....... Diameter.....-----...--..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..........................•--------....--•---••-•-•-•--•---•---------•--.. Date........................-................
Test Pit No. 1................minutes per inch Depth of Test Pit--.------........... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •---•-------------------•----------...--........----•-•--••.....---•----•-•-•--•••......••----...•--.........................................................
0 Description of Soil..................................................................................................:.......................................................................
V -------------•-------•---- :_� .---------•-----•-----•--------------------------------------------------------------------------------
VNature of Repairs or Alterations—Answer when applicable----X.7Kf.!�,..j.'/-.1 -�...-�.. '�1T..0 fh`- -..
---
...-- ..3 5... :� .f.!<..7.v�.�_ ✓t.S %cam src ------------------------------ ----------------------------------.
>� ---... ---r r
Agreement•.
The undersigned.agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental'Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been isss.ue.d_by the board-of health.
Signed ........ ................... ...3........6.............:..V
Dare
Application.Approved By ......0 J .. ,. ................................................................................... .....�...-./1...-.9A Due
Application Disapproved for the following reasons: ........................................................................... ........................................................
............................................................. ................................................................................................................................................ ........................................
PermitNo. ......7.�}-.....-....C Issued..................... ............................e .............................e......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Qlertifirate of C�omplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�n
y r
at ....................................... ........... Z..4........ ....... ........................................ ...........................................
has been installed in accordance with the provisions of TITLE 5Gof The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....91 7.-...�,�..0...��........ dated 3..-..��..� �..:........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... .. ...... ................................................... Inspec .......... .`........................ ...... .
-THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
DisVood Workii Tunitrudion f rrmit
Permission is hereby granted................Q-A.P -`=--- --------.......................................................
to Construct ( ) or Repair (� an Individual Sewage Disposal, System
atNo............................................. �- Z. ( t'�.l�ylc�, . U_ t rP -----------------------------•------.---._•_-_•...............•___.............._ r---._ ...._-. ...-
Street _
as shown on the application for Disposal Works Construction Permit No, l>.�..:.�_ Dated....5k.- .........
. ------------------------------
/�� _ / Board of Health
DATE----------------%�-•------.. .-----------.....----------------------- �./
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS