The URL can be used to link to this page

Home My WebLink About0327 ARROWHEAD DRIVE - Health 327 Arrowhead,Drive ,. r Hyannis P 270 063 v v � e e r ° r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address " Jason Ellis Owner Owner's Name information is Q1 required for every Hyannis ✓ MA 02660 10/20/2015 : page. City/Town State Zip Code Date of Inspection 4m en w1 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:When A. General Information fin the ut computer, on the computer, use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. Riker Land Construction ray Company Name PO Box 726 Company Address , South Yarmouth MA 02664 City/Town State Zip Code 5087766460 S14590 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/20/2015 Inspect Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal S m•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: All components inspected and no obvious signs of failure observed .Septic tank,distribution box and leach pit opened and inspected . B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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•3/13 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 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 FIND (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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 9 - , 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 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 El ® 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. CityrTown State Zip Code Date of Inspection 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system 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•3/13 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M y 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 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: I 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? i j ® ❑ 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: i ® ❑ 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 ® El 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins-3/13 Tide 5 Official Inspecdon 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 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Three bedroom residential dwelling Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2013= 134 GPD 2014= 127 GPD Detail: Hyannis Water Dept. Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons 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: t5ins•3/13 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis- MA 02660 10/20/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): General Information Pumping Records: Source of information: Barnstable Water.pollution Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: pumping was recommended at time of inspection for maintence for soilds removal. 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): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form k s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed in Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): interior soil pipe dry and free of stains Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast Concrete If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No . Dimensions: 5x5x9 Sludge depth: 10" tins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) - Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 4" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): -Pumping recommened asap and at minumum bi-annual Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ti 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert equal to single outlet pipe 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.): The distribution box did have some carry over observed and owner was advised to pump tank for maintence . Pump Chamber(locate on site plan): Pumps in working order: ❑ -Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 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 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Type; ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had 12"of standing water in a 6"deep precast leach pit . No stain lines above standing water line observed. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. City/Town 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.): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/302015 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 ❑ drawing attached separately �.5 r-.10A4- H' 7�crr 1 a = a 6' 313� Ao 3= �?7° t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 327 Arrowhead M Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Abutting property test holes ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Reviewed maps You must describe how you established the high ground water elevation: Reviewed test holes of abutting properties at same topo hand augur to 12'with no water encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form + o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. Cityrrown 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 ❑ drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 327 Arrowhead Property Address Jason Ellis Owner Owner's Name information is required for every Hyannis MA 02660 10/20/2015 page. Cityrrown 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE L :ATION 3 7 1�,o�o/Po SEWAGE # VILLAGE /T ASSESSOR'S MAP & LOT �70 'a�3 MPWmA-A-L6J16E=1LD%'S NAME&PHONE NO. SEPTIC TANK CAPACITY s£ /its S6�Fc is LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER 0 OWNE �� .9S `f'o-C£� .VsPfc o.- PERMITDATE: DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by 1 � ��'� � .� � �� , � . . • M � . �� Q.9 � . i � W i �� i I .-�� i TOWN OF BARNSTABLE LOCATION X XIPO' v /f rlJb SEWAGE # .20o,2' /7 U .4 VIL,TL.AGE ASSESSOR'S MAP & LOT k7 ® " ®43 i INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 i SEPTIC TANK CAPACITY c LEACHING FACILITY:(type) n' / (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER r BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ' VARIANCE GRANTED: Yes No �i� ys e � . . w M'� .. �, 1� �^� � .. " ` w . • � '�" .L' a �, No...... FEs......1...".......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for lliripwial Works Tomitriartion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( /<an Individual Sewage Disposal System at Locatioi \ddrrs5 _ f•••` s v�l .................................................... o. 4f Q-----------------•-----........ ` . . O ncr AddressA .... Installer Address Type of Building Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria (. ) 04 Other fixtures --•--------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench— No. .................... Width.................... Total Length..---............... Total leaching area....................sq. ft. 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......................... Lr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-----•---•---------------------•••-•--•-•------•----••••--•--•------•------•---•-•-----•-•--•-.............••..................•-•-........................ 0 Description of Soil......................................................................................................................................................................... W x --- ------------------------------------------------------------------------------•----•------------------------------•--..........------------------------------.. ................................ i U Nature of Repairs or Alterations—Answer when applicable....................�t . t� C.F.... /......8_04............ 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 Co:,&, n been issued by he board of health. Signe ?- ....... ......... ......... ..................... ...................................... -Application Approved By ...... . ..` .................................................................... ....... ....... Application Disapproved for the following reasons: ......................................................................:................................................................. .......................................................................................................................................................................�Z.",e ........ ......................... ...... Dare Permit No. ....�C1v.z..-./..7.o............................. Issued .......(. .. .. .. .:............................... ��:Y`h+ jsv+�;r.;.�r�w-V�:bJ"v..�*�'c+ w"u-,J..•ow.a�:_..- ,=.w �•..,�,..�...,.;�,�.,v..�uv-vim �" •.�✓w... .,, ..y�. "�,...,,-_w"•\.f`.•'.'`.°._�.4_^ Y. ... „N � -Y. ........ � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripngul Works C omitrnrtiun. 1rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( kran Individual Sewage Disposal System at: 3 of 7 �/�'i�ou• .......................ff£o9�..a..�-----�-`-�--.......---------- --------------•----°..-.��....°-6.3-----------...-----------------------•------------ le Lot 17 ...-.......................................................................... W - 1 /i/V C0 ncr 3.J ��/� _ Address G� T Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------•-------...........--------..........---------------------------------------------------------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—.Liquid capacity............gallons Length---------------- Width................ Diameter......:......... Depth................ x Disposal Trench— No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........... ............................ ,.� Test Pit No. I................minutes per inch Depth of Test Pit...................; Depth to ground water......................... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----•.....................................•--•--------------------.•------------•-.....---•-------_._.._.............--•-........-----•..................._. .O Description of Soil......................................................................................................................................................................... x U ............................-----------------------------------------------------------.................................................................................................................... w UNature of Repairs or Alterations—Answer when applicable.....................fir-'_.. ........... _..... ......./6: 0.............._.. ...-•---.....-•-----••--•---•---------------------•--------•-----------•------------•---............----••---------------------------------------------------•------.........................._•---•---• 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 Theundersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued•by the'board of health. . a Signed ..... ............................. 4e�vt -..................... AA ) ,. Dace ApplicationApproved By ............or..... A.............w/ .................. ................................................. L/��n,.................... te Application Disapproved for.the following reasons: ........................................................................................................................................ ................................................................................................................................................................................................................ ........................................ 1 Permit No. Gv 1 -..l. .i)............................. Issued .......y.Ia.1A 7 i Dace i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ILTWErti irate of Complial'ICe THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( by ....... ..:.. tiC.Q.........3., .......5.T ....w..... ............................ .......................................... �i // ....5ef at ........3..�..../.......... �/ '/f��.�'`�....../..... .......... .............../.....Y................................................................................ ..................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .2..!/u ..-..!...7�L................. dated ......`.��,?."�tt.�.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..l V/u- r— t ..:............................................................................................. Inspector ....:::1.......fi1:,...................................... ;.........r .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FEE......................... Disposal Wore Tnnotrurtilan "permit Permission is hereby granted.. ' -----------------------= - ... to Construct ( ) or Repair (^ ) an Individual Sewage Disposal System at No a•---------------- ••---•------... ... .-- .....••••. ......-•stre--et---_... as shown on the application for Disposal Works Construction Permit No..:........... ...... Dated............................._............ •--...--••-----••-----•--•----------•--------------------------------------------------••--------- Board of Health DATE................................................................................ FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS ' i �l s TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP 6z LOT O d `� 'INSTALLER'S NAME & PHONE NO._ A & B� CANCO 775-6264 .SEPTIC TANK CAPACITY .f fajo c£ ,/ 15®X LEACHING FACILITY:(type) n• 7 (sue) NO:OF BEDROOMS 73 PRIVATE WELL OR PUBLIC WATER 'BUILDER OR OWNER pre Re,t-FA, DATE PERMIT ISSUED: !,. Y-tea DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i Nil'3 I �.f -- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r V� 350 MAIN STREET & WEST YARMOUTH,MA L 508-775 2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS NTR SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RECEIVED PART A CERTIFICATION MAP 270 PAR 063 MAY 0 7 2002 Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 TOWN OF BARNSTABLE Owner's Name: ROGER PERLEAS HEALTH DEPT. Owner's Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Date of Inspection APRIL 24,2002 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority :ails g L, ' Ins ector's Si nature: �/��=2. Date: P ;2 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer, if applicable, and the approving authority. Notes and Comments '****This report only.describes conditions at the time of inspection and under the conditions of use at that time.'This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 C. Further Evaluation is Required by the Board of Health: N/A _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance xx This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below.invert or available volume is less than''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APR IL 24,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the,following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] r Title 5 Inspection Form 6/15/2000 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 289,000/2001 332,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A—TANK IS TO BE PUMPED AFTER INSPECTION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1989 PERMIT#84-292. NEW DISTRIBUTION BOX IN 2002 PERMIT#2002-170 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 15" Material of construction: X concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TANK AND COVERS 15"BELOW GRADE. INLET BAFFLE,OUTLET BAFFLE NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspecti on)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and Float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 16"X16",22"BELOW GRADE. BOX IS NEW APRIL 24,2002. ONE LINE IN, ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER ARE 34"BELOW GRADE.6"WATER IN PIT.STAIN LIEN AT 18".WALLS CLEAN,LIKE NEW.NO SIGN OF OVERLOADING OR SOLID CARRY OVER SEEN. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: _ Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS.MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. fit r 3; i Title 5 Inspection Form 6/15/2000 10 Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 327 ARROWHEAD DRIVE HYANNIS,MA 02601 Owner: PERLEAS,ROGER Date of Inspection: APRIL 24,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 26 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: Observation site(abutting property/observation hole within 150 feet of SAS) -Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain- You must describe how you established the high ground water elevation: USGS WELL DATA WELL AIW 230 2.7' ZONE B 3.7' ADJUSTED 23.3' t;;,t'L Title 5 Inspection Form 6/15/2000 11 0 - t) FS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF 1 f2 DEPARTMENT OF ENVIRONMENTAL P O��P CTION ONE WINTER STREET, BOSTON, MA 02108 617-29 5'00 RECEIAT NOV WILLIA.M F.WELD � � iElDY CORE Governor TOWN OF "NST*LE Secretary HEALTH OEPT. ARGEO PAUL CELLUCCI D; D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR' p� Commissioner PART A CERTIFICATION Property Address: 32�i ) 1 Rw101SAddress of Owner: S-TE RSDI\J Date of Inspection: 10 -11— `i 7 (If different) Name of Inspector: ` G a1.4 r I am a DEP approva system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: —C 0 P C P T I C Mailing Address: Z.o C3 Vkx—T E K< K t� a 1 I\1 S Telephone Number: .7 7 `ram — O 6 Rol 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: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails / -7 Inspector's Signatu L-✓ Date: �'� / 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 sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYS M PASSES: 17I have not found any information which indicates that the system violates any of the failure criteria a5 defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BJ SY TEM 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:twww.magnet.state.ma.usldep Printed on Recycled Paper { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 321 A a1L1xa1-f L o t, C— 1$ 14 y(}N tU� S' Owner: l\N A S T C-R S c 13 Date of Inspection: 10 - ( 7—9 7. B] SYSTEM CONDITIONALLY PASSES (continued) 41 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). Describe observations: 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(with approval,of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: FOLI 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 IS 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3Z1 (ZIZDw1+t Owner: M A S-V G A S-t,, Date of Inspection: 1 c, — 11 —9-7 DJ SYSTEM FAILS: You ust indicate ei;r,er "Yes" or"No" as to each of the following: 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. Yes No 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. � Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _.el Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. 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. 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. 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. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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 exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ILL H 2.2uw 1{,�(}l_,� b R l J E J.W-y (A-O t J,S Owner: M A S Z EFi<Sot1 Date of Inspection: l u — ( -7— 9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Z _ Pumping information was provided by the owner, occupant, or 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. / _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) i I I . I (revised 04/25/97) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 Z1 A 21Zcx�REA isaw'.c� (4�q rj 6 l % Owner: MA S-jEi2Sa� Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 33 0$.p•d./bedroom for S.A.S. Number of bedrooms: Number of current residents:Q Garbage grinder (yes or no):- Laundry connected to system (yes or no):_ Seasonal use (yes or no): Y AA Water meter readings, if available (last two (2) year usage (gpd): ALA a' (1 S`1900 Gu, 95 j(o `]yoo C.A,-'r+' (� Sump Pump (yes or no):4— A krj , 9 b'9 7 1 Last date of occupancy: UnXM v� COMMERCIAUINDUSTRIAL• Type of establishment: 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)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy°: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons L Reason for pumping: TYPE qF 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)'tI (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 321 {t_QAt�t rlp bV-WG,HJA'\11J; S A Owner: N'\A S T C R S0�J Date of Inspection: f o — 1 — l BUILDING SEWER: (Locate on site plan) . d, Depth below grader Material of construction: _cast iron 40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) it Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: '�_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: q� .t Distance from bottom of scum to bottom of outl) tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation,to putle invert, structural 5 of integrity, evidence of leakage, etc.) J� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 2--1 '� E, H`t A N N S Owner: Date of Inspection: t p —) -1- 1'7 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: 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: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:I`� (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.) • I (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION (continued) Property Address: 3 21 AIL ' tfE tkD t(Z t JE) f1 YA AJ N S Owner: M A S%E R 51 A Date of Inspection: 0 f . 9 7 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: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) u n0 CESSPOOLS: (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 (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) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.N PART C SYSTEM INFORMATION (continued) Property Address: 317 142LCL-"�I+Ew n 6(ZWc It 'SAIJN►S. Owner: MAS"CERSo►J Date of Inspection: t o — (7 --rj 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 0 i (revised 04/25/97) Page 9 of 10 I \ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Address: 3 Z� A {F-�D �RzJE/ H YA N 0 S Owner: M R S-TE (j S o tv Date of Inspection:f _ t 7_ l Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in yoown words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) Page 10 of 10 LOCATION SEWAGE PERMIT N0. VILLAGE, e � IN S LLER'S E iADDOlSS Q I ! QoI U I L D E R OR OWNER �L c • 4'� 1 Y DATE PERMIT ISSUED cel 4 DATE COMPLIANCE ISSUED Y i I , Jv �. ...pJJJ C7 I V ice.Q Ir I • i 2, 9 No...�V...... L Fss...:s...._........... Tfi`E COF"MONWEALTH OF MASSACHUSETTS BOARD OF HPALTH ....OF............. . Appliration for Disposal Works Tonstrnrtinn Vprrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a ......... .�-- _ !!._..._... .........................................................4 1-, ................ ovation-Address or tt 0, - - - ....... - --- ------------••------•-------•--------- Q.lc?� .4' ..... 1 Ow .Address W -'-- Installer Address Type of Building Size Lot._.:_..... .............Sq. Dwelling—No. of Bedrooms..........vl............................Expansion Attic ( ) Garbage Grinder `04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ........................... W Design Flow.................11 Q...... ..,.�-_,.�gal, ns per person per day. Total daily flow................. ��............gallons. WSeptic Tank—Liquid capacity.....__..." "gallons Length.............•.. Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No........ iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank01 Percolation Test Result Performed by.....•••• Date. ...... a Test Pit No. 1......_._.2'tninutes per>nch Depth of Test Pit.....:.............. Depth to ground water......................... 44 Test Pit No. 2....�Aminutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •-----..-_--- °__------•--•----..... ------- -------------•-------------- •---------------------- --•------------ ODescription of Soil..... � r, ...1 ---------------------------------•-•-------------...------------•---------------------.....-•-•--•--• � ---------------------------------------------------------------------•-•••..........••. w -----------------------•-----------------•-•--•----•--••-----------------------------------................................------------------------------------------------------------..........---- U Nature of Repairs or Alterations—Answer when applicable...................................................•......______..__._.__...................... . ---•----------•--•••-••---•..............••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.I .5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of health. D t Application Approved By.... -•--•-• ....... el�� ` Date- Application Disapproved for the following re ons:---••••-•••---•--•--••-•-•--••--....--•••••••••••••••-•-•-••......•-•-•--•----•-•-----••--••--••••-•-•......._.. --.......................................................................................................................................................................................... Date PermitNo...................................................-.:- Issued_...................................................... Date No.....» .. »g»Z' Fin$......................... _ T'I�E COMMONWEALTH OF MASSACHUSETTS BOARD OF H,FQ,LTH .....------. -..O F........... . .... ................................. Appliration for Disposal Works Tonstrur#ion Feruti# V... Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System : ... »_»»-•-•...... .....:..............•••-....•--•-•-••-••---.............. ----- -•-•----•-•---_--_-_---:.------------••-----__-__--__:_------__-__ - ___----- o •-ovation-Address '• or t o. ................».ram»». ........._.... .. ./........ ................... Ow _.......-•-••-..........••-•-...Address Installer Address Type of Building Q Size Lot___��, S Dwelling—No. of Bedrooms.........ra__............................Expansion Attic ( ) Garbage Grinde PL4Other—T e of Building _______________ No. of persons_._._._.__.__________.__.__. Showers — Cafeteria al Other fixtures __________________________ _ W Design Flow................__ _Q....._�..__.__._gal ons per person per day. Total daily flow_._____._..____.a.+�d..___________gallons. WSeptic Tank—Liquid'capacity_._..__.__._g ons Length________________ Width................ Diameter________________ Depth................ x Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....r__070-70biameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing to '-' Percolation Test Result Z Performed by.......... I�� Date............f�� '� g ..� Test Pit No. I__________ ____minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2.... .. '''minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Phi 0 Description of Soil.......... -------------------------------. � . , w ----------------------------------------------------------------------•---------------- x :_._._....••••••••-••••••-••••-•--•. •••----••••••••••--•-•-•••-•---••••-••••-••-••-•••••••••••-•••••-•--•-••-•--•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------------•-••--_._._._...•••-•-•-•-•••••-.................••••-•••--•••••••••••••••••••••••-•••••••••••••••••••••-••••••_...••_.._..•-•••-••-•-•••-••••••_--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boa of health. b M rigid- i= - 6 Q......- ` ••-'.�L -- --- a e ... _-_.... Application Approved BY .------••• -•---------- � ��_....-••••-•- Date Application Disapproved for the following r ons_______________________________________________________________________________________________________________» ----------------------------------•-•-----------------------......-----•---------...___--------.._........---------------------•-----•-------••-•-•-•••••••••--•••••••-•-..•-----•••••-•........................... Date +.r PermitNo.................................•-•-•••-•-•-•--•-•_.._. Issued_.....................................................» Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH OF................... !w t ......._.............. (Irdif irate of Toutplianrr b THIS IS TO CERTIFY, ThaIndivid3�"' °�age is 1 System constructed ( or Repaired ( ) Y •-_•-• •- -- �Cw�-�C...!..--- _ .............. _! Installer has been installed in accordance with the provisions of TITLE 5 The State Sanitary-Code as described in the application for Disposal Works Construction Permit No.._I6"y._J:'F_e.______.____ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �1 ' / DATE...................................................... ...�.I............. Inspector--•-----.............-----------------------. �/.. THE COMMONWEALTH OF MASSACHUSETTS BOARD F H TH r pa ........................................OF............ ....................................................................... -I FEE........................ Disposal Works "I io erutit Permission is hereby granted... ...t....-:�Gf:� _ to Construct or), parr ) an dividl S age Disp System at No... -- -_................... ----ee!�''=�` `�! as shown on the application for Disposal Works Construction Pe mit No_____________________ Dated.......................................... ........________..... _____________________________________ �u } Board of Health DAT ............................. --- ...........`j'....................... 't FORM 255 A. M. SULKIN, INC., BOSTON R ` It 0 / IN 12 44 DS L h 5� 53- 2 4 / cp OT 0 %09 X } . 0 or/44 \o 13�a� �-��-r�►,�a l4. U OOSFPC -Leg 04 y ` cal, ifRcseFt30 . torso 6A� LOT 43 (�I- .CiF .1 A°,K" �1 Lor4S �; 0 PROPOSED 35 + _ rf FOu.NDrjTsON —;L5 "--+ ZOniED )?� x V 100 +' A Q 10o Pl,,V..1W,DT.� I U U Fr, MlN 9e7-l3Ac.lc . , M I3 20110/ 10 �PLZN k4 y l O t 4 t!7 I ILIP sgrf.. 0 4 7 I 3G L✓ -- �(EYNBERG T:,.' I O�x Eac,E dF '0�"�� -- ,� v o.366 Ic • 9 TE�`G�'`� R0WNEAD VE. Lto' W j S�oNaL eN LEGEND EXISTING SPOT ELEVATION OxO P'i CERTIFIED PLOT .PLAN ' EXISTING CONTOUR --- 0 ---. d�:ii%F pair;, FI,41SHED SPOT ELEVATION ® %�, n i 4 `RQ�3E1� O !+4 ARROW HE FINISHED CONTOUR 0 �- �' �P, ,E lqyAw,vt rr BRI.1OF n IN �[� 1 R L C � BOARD OF HEALTH � �/ APPR OVED � 2 A JIBS fA.9LA Jb) ce SS• ,I DATE AGENT su �y SCALEt / " = 3o' DATE lf0Aa 2.9'4 1984.- �LOREDGE ENGINEER /NG CO. IN CLIENT. oa) I CERTIFY THAT THE PROPOSED ERE REGISTERED JOB NO. ��+033 BUILDING SHOWN ON THIS PLAN LAND DR.BY� D CONFORMS TO THE ZONING LAWS ; GIN ER RV Y OF BARNSTA'BBLE , MASS.y , 712 MAIN STREET CH. BY, •to Sf 2,gy N YA N N I S, MA 9 S. -SHEET - I. OF 2- DATE REG. LAND SURVEYOR /Y07F /F E/TNGR THE SEPTIC TANk OR 20 FT. M//V• ZZACNI/vG P/T ,4RE MORE TNA/V /j"JELO-W'� /D FT M/K GRAVE/Ai "`,V1AA4E7,Ee CONC•RIFTE C'OdEE SHALL ®Er A APO&4NT TO 4/tADE.�-4IV EX7-,eA /Ol•S CONCR!'TE AWN. P/TCN I�EAYy C^ST IRON CO{/�i! Sh'.4 L L DE USF� CDI�ERS �'P1�FT. I F/N OR/✓Ey✓.4 Y 2 te' MIN. CDNCRZ'TE of COVER CL EAN SA NO 6AC/C,= L L = LJQI//D LEVEL •. Z*LAYER IRON P/PE 000 GAL. • �� 1 • • • • • •• • e • /N•P p�C// C D/ST. 4 WASHED 57?�IVE M SLpr/C TANK 1 1 1 • lip • • • •• � ••• • ;;tir • 0 • • • DEPTH • • • s o WASNED STOV E `i a•• / 1 0 • • • • • • • • 1 �• o • *- ' • • • • • • •. • • r PRECAST SEEAAGE /NV4wR7 RLE✓AT/OWNS Pp /NV.ERT AT 4!//LO//V6 9_FT. prr l D f I O/AM• C CEE�V�TION� //VLE7 SSPIrIC T.4/VK �k"B FT, OUTLET SEPTIC TANK �B FT. GROUND Wo4TER TitALE //VLET D/57R/E/IT/ON @OX _F7. SECT/aN OF • ounzTD/STR/B/ rla,O " F7. SE,yVAGE O/SAO�S'A L SYSTEM INLET LEACNl1VCt PIT A-0 FT. TAQWLATION L ZACH/NG P/T SCALE NT CAE : y# _ /=O� DlMEN.S/ON A DES/6N CRITER/A 01MAWSION 8 G•D FT. NUAlCER OF O'somo0/NS 3 D/MENS/ON C�FT. ��"'�� GARQAGE.D/SPOSAL.UNIT Ny� SOIL LOG so/1- -r"r TOTAL EST/MA'rEo FLOW 2?y G.4L.�DA�' SOIL. TEST / SO/L j'L�ST2 NUMBER OF 4drACNING PITS OATS OR- SOIL TEST �O Z� SZ S/DE LGACN/NG PER PIT 519 RESULTS ivITNESSED dY sreO3r Crww�- 90T'YOM LbICN/IVG PER PIT-I8—�-,LSQ. FT l/ O-6 Go ,ti o 7_ZY� Gam^` PER COLAWON RATE At L Z MlNV//VCIf TOTAL LEACN/NG AREA ?,G7 SQ. FT. PEjlCOLA7va v RATE 2 2- M/1V.11lVCH RESER�/ELEAC//lN6AREA SQ. A7• �a. 4sq OF /A� r/n LO% fey `'�.�J,-11167-D a2(.�T' tN �qS 1p,J� ,� G/1R✓cL. � ��f �"'/�7`�if/j �I R-S� sRucE �, o • esRc ;g ELOREDGE EJ1AG/NEFR/NfG CO,/MG• ELDREC ` No. 366 a ;• � 7/2 MAIN 9-r, HYANN/9, MASS. Lj o� GISTS '� • L�J ND G/tOIJND kv,4 r&R CA/EN DATE No 51t�'1�`' �`—f Q G/t0[!ND "y+/ATER .'IT FrL.Ei! JOD /� 8Ya 3 3 SHEET Of Z