HomeMy WebLinkAbout0026 ELAINE ROAD - Health 26 Elaine'Road
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m , d DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_26 ELAINE RD. _
HYANNIS, MASS. oZ.3
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
Name of Inspector:_VANCE STEVE YOUNG - ` :-
Mailing Address:_ P.O.BOX 1592 f "Q
MANOMET,MA.02345
Telephone Number: 508-224-8332 f -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the inf rmation eported
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
Fails
Inspector's Signature: Date:_3/28/07
The system inspector shall submit a copy of niis idspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection_If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments In inspecting the septic system,due diligence and efforts were exercised in locating and
inspecting all relevant components of the system. However,I,Vance Steve Young shall not be held liable or
responsible for any omitted,misunderstood,or incomplete information in this report,nor any services
provided in reliance thereon.
****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 6/15/20,00 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_26 ELAIIVE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection._ 3/27/07
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:
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.
�I
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
existingtank is replaced with a complying tic tank as approved b the Board of Health-
*A
P Pig�P PP y
*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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_26 ELAINE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVI E CALIF.
Date of Inspection 3/27/07
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that
the system is not functioning in a manner which will protect public health,safety and the
environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_26 ELAINE RD.MASS_
HYANNIS, .
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
D. System Failure Criteria applicable to all systems:
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 cesspool is less than 6"below invert or available volume is less than 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.
—X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large 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.
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 H 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.
Title 5 Insoection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_26 ELAINE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1-MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
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)on the site has been determined based on:
Yes no
_X _ 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)]
Title 5 Insnection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_26 ELAINE RD. _
HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
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:_0
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)): N/A
Sump pump(yes or no):_NO_
Last date of occupancy:_APPX. l/l/07
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgketc.):
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:_UNKNOWN
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 a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: 21 YRS.PER AS-
BUILT
Were sewage odors detected when arriving at the site(yes or no): NO_
Title 5 Inspection Form 6/15/2000 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_26 ELAINE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:—cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth below grade:_16" .
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:_IOX5X5
Sludge depth:—4"
Distance from top of sludge to bottom of outlet tee or baffle:_26"
Scum thickness:_2"
Distance from top of scum to top of outlet tee or baffle:_8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):INLET AND OUTLET BAFFLE OK.....STRUCTURAL
INTEGRITY OK....LIQUID IS LEVEL WITH OUTLET INVERT....NO SIGNS OF BACK-UP OR LOADING
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(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 Inmection Form 6/15/2000 7
f
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_26 ELAINE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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.): .....STRUCTURAL INTEGRITY OK...NO SIGNS OF BACK-UP ......BOX IS 1
IN AND 1 OUT
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.):
Title 5 Inspection Form 6/15/2000 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:_26 ELAINE RD.
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection 3/27/07
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number:—I—
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: l
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.):PIT IS DRY.....SHOWS STAINING TO APPX 3 FEET ON WALLS OF PIT INDICATING AN AVG.
PREVIOUS WATER LEVEL......ALSO INDICATING APPX. 3 FEET OF LEACHING AVAILABLE AT AVG.
EFFLUENT HEIGHT......
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Title 5 Inspection Form 6/15/2000
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_26 ELAINE RD. ._
HYANI�TIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
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.
30'6" 39'
15' 20
El i
SHED
36'
27'
17'6"
1 I,
ELAINE RD
Title 5 Inspection Form 6/15/2000 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:_26 ELAINE RD. _
_HYANNIS, MASS.
Owner's Name: OPTION 1 MTG.CO.
Owner's Address:_ERVINE CALIF.
Date of Inspection:_ 3/27/07
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_30_feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_X Checked with local Board of Health-explain:_AS PER MAP DATED 2004
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: AS PER B.O.H.
MAP
Title 5 Inspection Form 6/15/2000 11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 02 6 ��q C! +�
a•�tiis /�� y�-c of � �-� r
Owner's Name:
Owner's Address: A IV So
Date of Inspection: �` 3o 4
7 co
CD
Name of Inspector:(please print) �}
w=A N
Wl"7 �� /� ' :.
Company Name: �4"V1,0 c CD wry
Mailing Address:
�+J
Telephone Number:C p
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 Se n 15.340 of Title 5(310 CMR 15.000). The system:
/�tis
Passes
t Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F .s
Inspector's Signature: /- Date
: 30 0�
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.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: CX,
✓i t
Owner: �0
Date of Inspection.
Inspection Summary: Check ,CD or E/ALWAYS complete all of Section D
A. �eases:
enot 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:
&�e or more system components as described in the"C "
section ne ed to be repor
repaired.The system,upon completion of the replacement or repair,,asnapp approved by the Board of Heallth,ewill pass,
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined" lease
explain. p
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is strucy
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the turall
existing tank is replaced with a complying septic tank as approved by the Board of Health.
"A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Tito+ Q Tnennnfinn T+'nrm(/1 G/7AAA 7
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ /CERTIFICATION(continued)
Property Address: I v%t ,Q
Owner:
a
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 s ste
is failing to protect public health,safety or the environment. y m
1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
T41a Iq
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 67z �i /� ,
Owner: /"(pl `�
Date of Inspection ,
D. System Failure Criteria appli able to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
91-11.pup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓✓Discharge or ponding of effluent to the s spool
surface of the o
ged SAS or cesspool
ground or surface waters due to an overloaded or
fig sp
Static liquid level in the distribution box above outlet invert due to an overloads r a
cesspool d o_ _logge..SA.,or
d depth in cesspool is less than 6"below invert or available volume is less than%:day flow
Required pumping more than 4 times in the last year N_OT due to clogged or obstructed i e s .Number
Hof times pumped gg P P ( )
_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.
5�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
st as
described in 310 CMR 15.303,therefore the system fails.The system owner should criteria
ct 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.
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 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.
T41a
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: C�' p r Rc�
Owner:
Date of Inspectio :
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
��g information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
=—fir as the system received normal flows in the previous two week period?
ave large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
_Were all system components,excluding the SAS,located on site?
-�- Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
v— Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes
sting information.For example,a plan at the Board of Health.
—C
_ Detenruned 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)]
T;t1^ G T"v"Prt;^"Fran ui amnnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: .Lq (4e
Owner.• / A�� G N 6vl G®/
Date of Inspectio .RESIDENTIAL 30 os
+LOW CONDITIONS
�l4 y
Number of bedrooms(design): Number of bedrooms(actual): �� ✓'� y(
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): •��o
Number of current residents: G o(w�
Does residence have a garbage grinder(yes or no):��
Is laundry on a separate sewage system(yes or no):.f� [if yes separate inspection required]
Laundry system inspected(yes or no):tio
Seasonal use:(yes or no): ef47
Water meter readings,if available(last 2 years usage(gpd)):
Sump Pump(yes or no): ZV
Last date of occupancy:-T
C
OMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): e„d
Basis of design flow(seats/persons/sgketc.).
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):
Pumping Records GENERAL INFORMATION
Source of information: Viection
Was system pumped as part of the (yes or no): 00P v
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping
TYPE SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altemative 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 compotLents,date installed(if lspow�and source off'Kormation:
P✓ P&-
Were sewage odors detected when arriving at the site(yes or no):
Titl`a � rnenortinn T.'nr.r.�/1 GMAAn li
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0 4 Gl tAci
�11
Owner: 141,1 0
Date of Inspection.
BUILDING SEWER(locate on site plan)
Depth below grade: �9 /
Materials of construction. cast iron _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
l
SEPTIC TANK: cate on site plan)
�I
Depth below grade: /3 �
Material of construction:_concrete_metal fiberglass_polyethylene
--other(explain)
—
If tank is metal list age:_ Is age confirm Compliance(yes or no):
confirmed by a Certificate of Compli _(attach a copy of
certificate) �
Dimensions: X It.?
Sludge de
pth:epth: 7 '/,
Distance from top qf sludge to bottom of outlet tee or baffle: o�� �♦
Scum thickness: Ltff ♦ �� /�
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottoms of outlet tee or baffle:
How were dimensions determined: F:-rile R'Q 5
Comments(on pumping recommendations,inlet and outlet tee or baffle condition'structural integrity,
a;sas jelated to outlet invert,vidence of le ge, tc.): liQ d levels
a W" h dJ. w -AG4.t 1 e.
'/O �� S I N C � �'► f O a
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(on pumping recommendations inlet and outlet tee or baffle condition'structural irate
as related to outlet invert,evidence of leakage,etc.): lty,liquid levels
Titles IZ rnc—u t;^n 17^—A./1[/')AAA 7
f
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0? !o — Cl I✓c—
a rM.✓ 0?�G IV/
Owner: �o�O
Date of Inspection: 0 0
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: goons
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: /lam (if present must be o ened locate on site plan)
P )( P )
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: /V(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.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection.
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chafnbers,number:
leaching galleries,number: • S `�
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.): Q // / vt 1/ ,�7 t '1i C/ 7 ✓?3�♦
CESSPOOLS:/V (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: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
T7rL. ¢ T._ 0
Page 10 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C2- �=. /a ►'1C_ ��
Owner• 7
��titirl, �
Date of Inspecd O O j
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.
U
d/O
Ce mer4
l� ! t , _ ko
�9
the to
�� 39
Titla 'Z inenarfinn 17nrm 411 ailnnn 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: t2 1� ZF/4 t„% R�
Owner: /"L b/14
Date of Inspection: o
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water `01 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-ex
plain:
Checked with local exca
vators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Cl
Titl�a Q TnenPrtinn Rnrm!./1 G/'7nnn t 1
r
.Cot' 26
/c>S:Da 1-61�G 61 pit j
W/2 1 .tone
0 �c g H 1500 ri.: 267
39.z _ 34 =5�19 capd
'
"0/
.Cot 25 G z C>GiiJ .o le f Q Xo-t 28
o I
. . , �� N ... .. A. i
£C. �11.3: \
30.0 43.c ! .
I I
re I .('at 27
10,S00 S9 /Ut Cape tw--w-'t ny
3 4q katbo2 Road
/dNaruavi, lVl.: -.0
Scate
I 41'O Sate 8'-2c
LA
I
i P4,o?
1500 �.5.9.
1-61Y- 61pit i!"'i
h' ,h
; ,
.1
_.
,2' If �
kP.tch Ran:�L) .4'ahf7d .Cn kl yanniA: /Ila I
9o2 Dav id 5tottA
t 'Pirr�;.Cot 27,ai .down on a plan og nC�i f -ho! tn.. ..._. _...___.
Erred +ceco t l !Lt p fare bk. 165 p 41 I
v u owe ia�e on an a� de tw t
f �e l3oau7 0� /QP
j JP�]t/ i t #/)-6055 Jlie goun&tion alwwn on -thii plan -ii.tocated
Made 8-13-86 on •the yaowa ai elwwn heteo and reet. -the.
lijit: N. .Ce i tyaPh aetback S 2P enrPnt� o the `Down ol, ga44u tab& q No wa--A encowrteAed ti
Xe44 Van 2 rri.n pea 1" bate 10-30-86
top to[, oaf 0
ILN6
eoa zae (coaivie No.32490 pc
and and q EO
� clsrc4
a
bony bony
9F AfA�f4p%,
J.;
r ediurc ncecti urs o X .
and and r„ � i
bon bon 4/$ `t 1 ;
F
i ItP
� 7r
I;
2G.S ZG.? j : j j
-9�,
THE COMMONWEALTH OF MASSACHUSETTS
B4OARD (OF i�°EI ALTH
.................cam. ................OF.........Ru .L�i s - -..._..._........... -
Appl ration for Asposal Works Tonstrnrtion Permit
Application is hereby made for a Permit to Construe (V) or Repair ( ) an Individual Sewage Disposal
System at:
_I.Ln.e4....` ........_._..._ ................. ��...._.__.
+ ti d eaa•a
a C1 ►.... ._r_Vr,51.r1.............................._..................... ... .�. C.nl�'► S.K .r Lot No_-..--._.-. .......... :........'
zs Owner ndd ��zs
jj Cd11l zLS
m Installer Addreaa f•
al Type of Building Size Lot_:M..A�.......Sq. feet
Dwelling—No. of Bedrooms._.......................................Expansion Attic ( ) Garbage Grinder ( )
d Other—Type of Building ............................ No. of persons............................ Showers ( ) —Cafeteria ( )
Otherfixtures ................................................................................
W Design Flow............................. -----gallons per person per day. Total dail flow..3�-----..._------ .-.-__-.-._.gallons.
WSeptic Tank—Liquid capacityl. P..gallons Length.�4.G....Width..: -2`.Diameter...:-.—.......Depth_s'.A. ..
x Disposal Trench—No.....................Width....................Total Length....................
Total leaching area.............._.._sq.ft.
Seepage Pit No..............1.... Diameter.......AO.'..... Depth below inlet......<_'........Total leaching area...,?.Z.....sq.ft.
N Other Distribution box ( ) Dosing tank ( )
a
Percolation Test Results Performed by...... i..�__C.�r�[ .. ^'�je�!✓vi.............. Date....!"Z.. ...........
.l Test Pit No. 14*1.* Z.-minutes per Inch Depth of Test Pit.....1,2&. Depth to ground water.......'
k. Test Pit No. 2....4......`..minutesper inch Depth of Test Pit.....Z2sh'. Depth to ground water........................
RS .....------••------..............•'---......_._......._...............................__......_....---------
Description of Soil... �...r '.._.. '...f,..A f 4 S! .. ...f3p!y /l1- '
y.... ��<�..I/''�,rF 3e.✓ ...................
U ............................................................................................................... ....................................------------------------------
..............------------
UW .......-----...................••---...••---.....••--------...••-_....••-•--•--..........._..............•. -
Nature of Repairs or Alterations—Answer when applicable......DESIGNING ENGINEER.MUST..SLIP..EA.VISE......
.
__ 1NSYAi LE►TION AND CERT)�1(- .y(RIIIMG...__.
..
Agreement: THE 5S'SYEM UVAS INSTALLED IN STRICT
The undersigned agrees to install the aforedescrib Individual Sewa� I�i �s��ystem in accordance with
the provisions of TITLE 5 of the State Sanitary Code a under ' d f ther agrees not to place the system in
operation until a Cer' to of Compliance has been iss d y the
S' ed_
Application Approved By.................... ....... ... ...... 1.I x['�n.................. ;•- c �.
Date
Application Disapproved for the following real
........................................................................................_............._...............................................................................------------....
Permit No.-. .......................-- Issued....._....
Date ..___._...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................
T tifirnte of Tomplianre
y. THIS JC TO CERTIFY, That the Individual Sewage Disposal System constructed (x) or Repaired ( )
b 1..._.0 oX''.•..:.....................................•---.....---•--.....................i...:........._.....,....
..._......
in. 11" — """""
at._�..........................Z ._... ..........
.:_..............._ .
has ten installed in accordance with the provisions of TIT - 5 of Th State Sanitary Code as d�e���¢¢ 'bed in the
a�alication for Disposal Works Construction Permit N........_._..�._'. .f:. -...... dated.-..._.�1'..�'."..lf. .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE`:::..........15 l L..-K�..............................:... Inspector..................... . ..............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF�HEALTH
ILTH
...........................................O F.............�. 1..:..!.-.j v QU
.............
No......................... ...... ......... Fee............:..........
S ells- aispos -�W/ or/yks To striation Permit
Permission ' hereby granted........ _Aeltt.............1—,!;iv.S-.........................................................................
to Construct ( ) or Repair ( an Ind'. idual Sewag Disposal ystem
_...._ )y . �1,J ti i at No---
as la?........ �. V te. . . E'........... l .. -........5................•--•------------••-----••-•--'--
5tred ( q
as shown on the application for Disposal Works Construction Permit q..1.6..`._..!_�J Dated.........9..-- - •C�
�- -•-••--••'•.• $bard of Health
DATE............I.....................�.---...._......_........_. l!
FORM 1255 A.M.SULKIN,INC.,SOSTON
Upper Cape Engineering
P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 . (617)362-6281
Jan .21 , 1987
Barnstable Board of Health
397 Main Street
Hyannis, Mass
Dear Sir,
We have caused to inspect the septic system (s) located
at lot 27 Elaine. ave Hyann-is # 86-915 and lots 55, 56,?nd 57 Estey
Ave. Hyannis and they were found to conform to the plans submitted
by All Cape Engineering.
Than you
ohn Jacohij
TOWN OF BARNSTABLE
LOC kTION �bT 7 ���.✓�' {oclSe SEWAGE #
WLLAGE , ASSESSOR'S MAP 6z LOT a 4 b I l- !D
Uo
INSTALLER'S NAME & PHONE NO.,s'`/a e-1+1 C ,�—3 7
111 .
SEPTIC TANK CAPACITY /5-
LEACHING FACILITY:(type) C�sa cm�i' (size)
NO. OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
o DATE PERMIT ISSUED:
DATE ,COMPLIANCE ISSUED: !��-
VARIANCE GRANTED: Yes y No
Z ..
No. d....._.. ' Fps ....._........
THE COMMONWEALTH OF MASSACHUSETTS
BOAF�® OF HEALTH
.............. . .......... ...OF......... ....................------.........................
Apptiration for Biopoottl Marks Tonstrurtion Permit
Application is hereby made for a Permit to Construct) (V ) or Repair ( ) an Individual Sewage Disposal
System at
_.j.C4-�-!2.e.. ....7-)� .... �1J��Y1'i5...........................................�-7--..... .... •..................__.
ocatio - ddress or Lot No r
1 ,���. .. c' --------------------------------
Own- cSL ..._......_ = r: ?nr sY t �i
.. ....._...... ... ..
Addres
Installer Address _ -
dType of Building Size .......Sq. feet
U Dwelling—No. of Bedrooms...........3................. .Expansion Attic ( ) Garbage Grinder ( )
'_l Other—T e of Building .............. No. of persons..............._...._....... Showers — Cafeteria
P4 Other fixtures ------------------------•-••••---•-•-......••....• ...
_-'r!......_gallons per person per day. Total daily flow-_1 .............................
W Design Flow.......................•-- - gal P P P . Y• Ygallons.
WSeptic Tank—Liquid capacitylga#•-gallons Length. 6` `... Width..:g..tkr`.. Diameter---_n=...... Depth.g.'
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...............1._.. Diameter......eO`..... Depth below inlet............... Total leaching area...a`7.....sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...... .............. �".. . ��_...__Date � .
Test Pit No. 1 _ _minutes per inch Depth of Test Pit.....` °_. Depth to ground water...... ..........
Test Pit No. 2........._"..minutes per inch Depth of Test Pit..... h`. Depth to ground water........................
a .....•-•---•-•-•-----•••-•••-•--•--••...................................•-••-•-•------•-•-----•-•...•......................................................
O Description of Soil... ..... .°_.. � ¢ ! e fit/! j/L! ?t/h! .
x
c.� -------------•--......
. ----------......-----------------------... -------------------------------------------------------------------------------------------------------------------..
------•--- -•---•--•---••-•••---••-•••--•-••-•--•••••-••••••---•---••••-•••-----•...•••----•-•••...••••-••-•--•••-----•-••-•••................
x DESIGNING ENGINEER MtJST..SIfPEE3l�1��......
U Nature of Repairs or Alterations—Answer when applicable...... ..............
1NST_ALLATION AND CERTIFY.IN..WRlT1RSz.._...
7 H SYSTEM VVAS Agreement: 1 INSTALLED IN STRICT
�^C�'RDAN
The undersigned agrees to install the aforedescrib '}Individual SewaFdEDT�pF1 I9rystem in accordance with
the provisions of TITLi, 5 of the State Sanitary Code �.he under *,, d f rther agrees not to place the system in
operation until a Cer to of Compliance has been iss Zd the d/ `
Signed........ .�.... ..--.. _..�...--- ............................... ...
. .
Application Approved BY (. ! .-----•-••-----------•-........ ..._�__l�te- �
Date
Application Disapproved for the following real s: .........................................................................................•...•.•..........-
-----....-•---••-•-•.................................J•-•-•...--•••••-•-----•••-------------------......••-•••-•-......._..--•••-•-•••-•••••---•...•-••••••••••-•-••••••••-••••••••-- Date.......
Permit No.._ �?. ...4-�.-/ ------- ---- Issued_......-----•--••••.
...............................Date
--
4F
No, FEE ..........
THE COMMONWEALTH OF MASSACHUSETTS
1;;�_OARD OF HEALTH
................. J.. OF.........Al ........................
Appliration for Disposal Works Tonstrurtion Permit
Application is hereby made for a Permit t4Co Anstruc or Repair an Individual Sewage Disposal
System at: a,—
............................Etain.e..........U..!................... ........I...................................��7---------------------------------------------
catio - d ess I.LQor Lot NoQ. •
...4b
.......................... . ..................................... .44..C
Owner Addr or 1.4. b& "DR
....r A Q
-----ArLh ... ................. IqSk row j. ..... .....
Installer Address
U Type of Building Size Lot___ ......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No, of persons.,----------------------------- Showers Cafeteria ( )
PL4 Other fixtures .................................................. ...........................................................................
!I1 .........................
W Design Flow..............................5..�E......gallons per person per day. Total daily flow..... .............................gallons.
P4 Septic Tank—Liquid'capacity l�-.!?�q..gallons Length.Z�.'��:'.. Width__.:? -.. Diameter__-__----.__.._. Depth..
Disposal Trench—No..................... Width___________.______._ Total Length..._.___.___....___. Total leaching area....................sq. f t.
Seepage Pit No................ ... Diameter.......Z�:...... Depth below inlet......5;........... Total leaching area__ -.7....sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results. Performed by.........
................. .................... Date..... ...........
Test Pit No. l4°=5A..�.minutes per inch Depth of Test Pit...... Depth to ground water.._._._'-'_______.....
rZ4 Test Pit No. 2....*.......__minutes per inch Depth of Test Pit______ Depth to'ground water..._____!- ......
............................................................................................................................................................
0 Description of Soil.... ............ ......................... ..............................................................................
.................
U .........................................................................................................................................................................................................
.........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.............................................................I..................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribe ndiv dua Sewage Disposal System in accordance with
?1 i( !
the provisions of T I TLE 5 of the State Sanitary Code&-flilie under d fu thher agrees not to place the system in
s y e 0
operation until.a Certi6eate of Compliance has been ss y the b
Signed------------ .......................... ....
/ ,�
Application Approved By....... c . 4.e4..1.k7N............................. ...................Y....e
.
S:..........................................................................................7 Da.te.............Application Disapproved for the following.reasI
.......................................................................................................................................................................................................
•
Permit,No... ................................. Issued-.-..*............................. Dat....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J............OF........... ..... . ...........................................
(Intifiratr of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by-_---- ......................................................................... ...j.................................................. ......CA�X:ty
aInsttller
....................
at.... ........................................................................................I. _116e......... -------------------------------------------
5 of The State Sanitary Code as described in the
has been installed in accordance with the provisions of TIT C The�57
application ...... . ...... . ................._
for Disposal Works Construction Permit No....... ...b. dated_....__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
............. ---------------------------------------------------I... Inspector...................... i-------------------------------------------------
DA-EE..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................0 F............. .....................................................
No......................... FEE............—7.7•...........
Dispos�
Permission Works Tv eristrurtion 'r mit
p
herebygranted........ .............. ............................................................................is
to Con or Repair an Indpridual Sewagj.- Disposaktystem �4 AJ V
A at No.... ---------- ................................................
stle�i -----------
I
as shown on the application for Disposal Works Construction Permit Va_Dated........ ..........
7 -�41-�. .......& .-�... . ...........................
ard of Health
DATE............I..........................?............................... -------------
FORM 1255 A. M. SULKIN, INC., BOSTON
'Upper Cape Engineering
P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617)362-6281
Jan .21 , 1987
Barnstable Hoard. of Health
397 , Main Street
Hyannis, Ma s s
Dear Sir:
We have caused to inspect the septic system (s) located
at lot 27 Elaine ave Hyannis # 86-915 and lots 55, 56,and 57 Estey
Ave. Hyannis and they were found to conform to the plans submitted
by All Cape Engineering.
Than your
V-)ohn Jacoht
y
t '
t .C'oz 26
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c>s.00
1-6 6 f pit
"�a ;-n' t3' .38.�
atone
mq® l 50034 u.. =267 I ;
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39.2 .
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.Cot 2 S �5 v z . /;\: .0 —Pot 28
j I (�R0FPo417 391. .
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lo-t 27
10, 500 �S9 AU Cape tcr d 49 lda�bo�t
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icS.00.
�caCe I r'130.
4!.0 3ate 8'-26 .96.
£Carve road:. ''40 r wtide . .... _ 3
,
I
i 1�aogc,Ce. 11t0 'scc�e
f; I 1500
I
M ��! 1-6 x 6 pit
�stor2e
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She-tcA Nan q� aC�l in Pganvci� >~/a. i
9o� Wwid S7&otto
.27�aa ahown on a-plan-o uC �.-. .��ofi to
and 2eco2ded'�n pt an bh. 16 S p�. 41,
rtwat,.,o ahown ate on cui 'cl�iu- d tzmt. j
Mcte: revit t5� n.�tcZe i5oaiuZ-o l ec�.tFc-
hit 43-60S
rniade 8-0 r 86 . S : I
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+ P. �.�.2.
g.o - 39:z DESE`GNItJG;ENGIN_ ER M ST SUPER
I i ;INSTALLATION AND CERTTT�FY:IN: WRITING
37..E, p IN -
37.; _.__, _._. rt. ... H-G-SYSTEM 1RlAS...INST LED._. S7RIC
coaa/j.e coax 'O'PLA
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bony and
bonyik OF
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a
boned: honey' JqN I S-
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