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Home My WebLink About0021 GENERAL PATTON DRIVE - Health 21 General Patton Hyannis A= 292-108 j TOWN OF BARNSTA.BLE . �� .oOATiorr 1 e/'oc l {�cvw. sEwACE # II, III,LLA-GE �✓►�1 i� 1}T ASSESSOR'S AIEAP &LOT NSTIALLER'S NAME PHONE NO. ;EPTIC TANK CAPAC1TX .EACHING PACILIT7C: (type) �(` }� (size) TO.OF'BEDROOMs_ a WILDER OR OWNER, 'ERMITDATE: CO`RLIANCE DATE: !cparation D?ise�oe Between the: t r 4aximurn Adjusted.Groundwater Table to the Bottom of Leaching Facility eet xivatc dater Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ,Age of Wedand mid Leaching Facility(If y wetlands exist within 300 feet of lun fucili uvnished by �G✓n =�// n i� � i � � . . � " . o - , nO r , �� 4 ,� � � v � a r � W ��,.,_ Commonwealth / o onw alth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 : 11-19-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 ' Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Evaluatio by the Local Approving Authority - 11-19-13 spector's 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•3/13 Title 5 Official Ins ec rm:Subsurface Sewa e�is S Page 1 of 17 P 9 9 'l Commonwealth of Massachusetts w Title 5 Official Inspection Form p or e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 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 y in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 exfiitration 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is Hyannis MA 02601 11-19-13 required for every y ' page. CitylTown 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): . f ❑ distribution box is leveled or repiaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1: System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ Y P P Y (SAS) 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 Static liquid level in the distribution box above outlet invert due to an overloaded El ® q or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts ll Title 5 Official Inspection Form s g Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M s 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. CityTrown 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. Cityfrown 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: f 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? Z ❑ Was the site inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. .' ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 ..{ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: k 10-2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: • Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow.(seats/perso n s/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 Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5- Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM s 21 General Patton Dr - Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis annis MA 02601 11.19-13, page. City/Town • State Zip Code Date of Inspection D. System Information (cont.) a Approximate age of all components, date installed (if known) and source of information: 1988-leach pit added Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18" 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.): Good condition. Septic Tank(locate on site plan): 41' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) µ w If tank is metal;list age, years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6x6 block cesspool Sludge.depth: 0 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Empty Scum thickness k 0 Distance from top of scum to top of outlet tee or baffle N/A Empty Distance from bottom of scum to bottom of outlet tee or baffle N/A Empty How were dimensions determined? 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.): 6'x6' Block cesspool acting as septic tank in good condition with baffles installed. 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 Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis' MA 02601 11-19-13 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 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•3113 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 M 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 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 N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ 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 wM 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields. number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: .Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 30" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration SEE SEPTIC TANK Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer I 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every y H annis MA 02601 11-19-13 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 • 40 rt \ C r r t5ins•3/13 „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water I ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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® ( hole within 150 feet of SAS 9 ) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3J13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Forme Al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 General Patton Dr Property Address Richard Leeret Owner Owner's Name information is required for every Hyannis MA 02601 11-19-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this forth.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information - - I l� , 1. Inspector: � --t Shawn Mcelroy —� Name of Inspector Upper Cape Septic Service Company Name to 29 Atwater Dr _ C-1 Company Address E. Falmouth MA 02536 City/Town State Zip Code .7 1-508-495-0905 S13971 !"p 1 Telephone Number License Number r 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 4-22-11 Inspector's 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. (,,& 5 A I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 21 General Patton Dr Property Address Bank Owned (Contact David Holt @Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 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 j;A) -System Passes: i® I have not found any`informabon 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: System is in good working order with no sign of failure. 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•11/10 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 21 General Patton Dr Property Address Bank Owned (Contact David Holt @•Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): - ' - r ❑ 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 pipes) are replaced _ ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): .. • .a ., .. .. . .r•+ r sr. ... .�.. . .. ' r ...r a, C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . = w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ..r 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 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 1/ day flow t5ins•11/10 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 21 General Patton Dr ' Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town 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 o'r 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. ❑ 0 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 " ' - _ '•T` ` .= 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 21 General Patton Dr ° Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 - page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑. ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? 0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information , Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface•Sewage Disposal System Form-Not for Voluntary Assessments 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes ® No Laund y,system inspected?; - ❑ Yes ® No Seasonal use?: ❑ Yes ® No Water meter readings,.if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-2011 Y. - - } 1, 4 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on.310 CM 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? f ❑ Yes ❑ No Industrial waste holding tank present? .. ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i - 9 P Y rY 21 General Patton Dr Property Address Bank Owned (Contact David Holt(0Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis MA 02601 4-22-11 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? '' ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑. Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator'under contract ❑ Tight tank.Attach a copy of the DEP approval: r ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code • Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 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, evidenced leakage, etc.):. , Good condition. Septic Tank(locate on site plan): 4" Depth below grade:, feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) i if tank is metal, list age: t years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate), ❑ Yes ❑ No Dimensions: 6'x6' block cesspool Sludge depth: 0 t5ins•11110 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 ,M 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town 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 N/A empty Scum thickness 0 Distance from top of scum to top of outlet tee or baffle N/A empty Distance from bottom of scum to bottom of outlet tee or baffle N/A empty How were dimensions determined? Tape Comments on pumping recommendations inlet and outlet tee or baffle condition,( p p g structural integrity, , 9 liquid levels as related to outlet invert, evidence of leakage, etc.): 6'x6' block cesspool in good condition acting as main tank with baffles installed. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not,for Voluntary Assessments.,, 21 General Patton Dr Property Address Bank Owned (Contact David Holtl@ Today Real Estate 1-800-966-2448) , Owner Owner's Name information is 1122 MA 02601 4 i anns - - - required for every Hyannis ., City/Town/Town State Zip Code Date of Inspection page. Y P P 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 co6struction: f ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: • gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No r Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fog Voluntary Assessments M 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 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 N/A Comments (note if box is level and distribution to outlets.equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 t M 21 General Patton Dr , Property Address Bank Owned (Contact David Holt @ Today,Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal. t❑ tleaching chambers }t '' numbers ' ❑ 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 in good condition and empty at inspection with stain line at 30" below inlet invert. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Noffor Voluntary Assessments 'GSM ` 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 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.): 4 l 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.): t5ins-11/10 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 ; 21 General Patton Dr ,► a., „ r, Property Address Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448) Owner Owner's Name t information is Hyannis MA 02601 4-22-11 required for every y 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 961 n t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments 21 General Patton Dr f� . Property Address Bank Owned Con - - - tact David Holt 6-Today Real Estate 1 800 966 2448 ( @ Y ) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ` El Check cellar ❑ Shallow wells Estimated depth to high ground water: 40' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 40' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. M 21 General Patton Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 4-22-11 . page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater I - ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate.file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I�OMMIDNWEALTH OF NEASSACHUSETTS IExEcurn E OFFICE OF ENVIRONMENTAL AFFAI.&-s DEPARTMENT OF &NMRON3MENTAL PROTECT101i ^r TITLE c OFFICLA.L IN'1591:CTION FORM—NOT FOR VOLUNTARY ASSESSMENIN 15118SCTRF.A,CE SEWAGE DISPOSAL SYSTEM FORM PART Ak CERTIFICATION Property Address:—.2i_treaetyjl _?Lftwt. Ir`vef Owner's Name: Owner's Address: 'L L , 1 z Date of Inspection• O i _ NameofIaspe�se ts` , print Company 1eTaimec r n,M Q uk� tomTO Mailing Address: '4 Telephone CERTIFICATION SFA.TEMEN T I certify that I have pers=dly inspected the sewage disposal system at this address and that the informatics ri ,arte;j below is trace,accurate and complete as'of the time of the inspe�.;ion. The inspection was perforated based on, y training and experience in the proper function and msinftnnce q)f on site sewage disposal systems.I am a IDil approved systtm inspects r i?ursitaot tqt Section 15:340 of Title S(310 CMIa 15.000), The system: passes r Conditionally passes Needs Further Evaltbition by the Local Approving Authority F ' ' Inspector's Signature; e Date: The system inspector shall i.u1 suit a copy of this inspection tope rt to the Approving Authority(Board of Flesihl or DFP)within 30 days ofconip:eting this inspection.If the system is a shared system or has a design flow of 10, 00 gpd or greater,the inspesmr altd the system owner shall submit.be report to the appropriate regionsl offtc a c,f i k authotity.P. The original should b:satat to the s;,+stem owner and copies sent to the buyer,if applicable,and the appru ping authority. Notes and Comments 714(j 14 .54* 4ra-Kcc 4, ' a o wo) ;41 ""This report only desceibes conditions at the time of inspection and under the conditions of use at 1;:h,i is time. This inspection does:xot address t,ow the system will perform in the future Baader the same or E 061 reat conditions of use. Title 5 Inspection Forth 6/:12000 naQe i F N Page 2 of 1 1 OFMCIAL 11441ECTION FORM—NOT FOR VOLUNTARY A.SSESSM U-117 11 SUBSUI3F.4,+CE SEWAGE DISPOSAL SYSTEM INSPECTION FORD+I PART'A ; CERTIFICATIVN(continued) Property Address: ? Owner: Date of Ins;.peetion: Inspeetion:5umms :' Ch*ek A,B,tr,l)or R I 4:oim alll of ry tl..See oa D �! System Passes: 15 kI have not found any:nformatior,which indicates that;any of the failureI criteria describe¢in 310 CM.R. 3O3 or in 3 10 CMR 1 5304 exist.A,niy ikilum criteria not,ovaluated are indicated below. Comments: IL System Cond6tlo !h Paws: One or more system component$as described�gibe"Xasv�Ws 'section need to be replaxd c:- repaired.Then system,up atmpleeior,cfthe replacement or e Begird of Health,, +vil1 .us. Answer Answer yes, no or not del ermined(Y,Tl,T1D)in the for tstatements.If"not dcterminui"pl e explain. ne septic tank is:ai:tal and over:20 years older or 4*3tic tank(whether metal or not)is structtmjll;q unsound,exhibits.subst�titia! iafiltratio:n or ex$ltration ;fin=is itrmninent. System will pass ins;,e,:tic n if the existing tank is replaced vei th a cornplyimf septic teok ttpp M ed by the Beard of Heahh. 'A metal-seoc Mile will atcss inspection if it is y seumd,not leaking and if a Certificate of Cosapli1..1::e indicating that the tank is less than 20 yaws of ble. ND explain: - Obserradon of sevri.8c:backup ed 0a 9 W�SN1.water level in the distribution box due to T:er�:I:.a obstructed pipes)or due.t o at br+ok 11 or stele y�will di, ib!=t}on box.S pass inspection if(�vAb approval of Bimt+d of)!3eal��): ._ ..,, , . , br®Itm l OjnA@leoed obis i tts&toved diet: boot b Inabd ar replaced ND explain: The system ire!;)'In ping mir a than 4 times a year c.ue to broken or obstructed pipe(s).The s;croert wal pass inspection i with ap;j oval ofdW flood of Health): brokam pipe(&)are replaced ®obstruction is rettmved :VD explain: T 2 P • w Page 3 of 11 OFFICIAL Mrr-TECTION FORM>NOT]FOR VOLUNTARY LUNTARY ASSESSMNI 'f SIBSLIMIXX SEWAGE DISPOSAL SYST'EM INSPECTION FORT![ PART A. —CERTIFICATION(continued) . Property Address:. X6p Owner: Date of Inspection: Y t C. Further Evaluation is Required la'?the Board of Heesh : Cornditions exist w hi:h require,further evaluation by the B d of Health in order to determine if the a:� tees. is failing to protect public bcalth,safety 4w the envkotsment., 1. Systesn will pan t Ili less..Board of Health detarmmin in accordance with 310 CMR 15.303(8)�(1)) t', t i,he system b not ruatt;antning Ina 1msanner which evil ratect public health,safety and the enviro nnn�n�t: C'esspool,or pear,),is.within:.O.feet of w wilts _ C`esspoci or perry is-witlsin_'0 feet of a vegetated wetlaand or a salt marsh 2 Syste®n wi3l fail 01191ss tlae 3"r-d Health(and Public Water Supolisr,if any)determines built ;tie system is bactioning lit is manner.d t protect$the publk health,safety and environment: T. he syswttr has.�septic c imd'$oil absorption sytitem(SAS)and the SAS is within 100 feet oi!'. 1 s rface water supply x trib - to a surface water suplsly. The system has a,sep ' tame and SAS and the SAS is vMhirn a Zone 1,of'a public water supp!r The system has a s tic tank and SAS and the SA;;is within SO feet of.a private water supply.virel i Ile system ha:a tic tata:and SAS and the SAIS is less than i 00 feet Vbut 50 feet or more E asn private water suppl;+ylrell"*.Method used to detern Une cUmance •*This system pas os if the well water analysis,petform�:d at a DEP certified laboratory, for roliforca. bacteria.and vola •e organic coma*ands indicates that t.;e well is free from polhntiaa from that fac.iliq-i end the presence of ionrta nkrogett and xnitfate&*%dn is equal to or less am,5 ppm,provided that:no i iber failure criteria triggered.A copy of the anxalysis miss;be attached to this form: 3. Other: a k a w Page 4 of 1 l OFICIAL I143FECTION FORM—NOT-�OR VOLUNTARY SUBSURF''A+CE SEWAGE DMWOSAL SYSMM INSPECTION FOR d C=TIiT'ICAT 1D14(con med) i Property address; Uwaer: r Date of Inspection:4P72=9' D. System.Failure Crite ran applicable to all systems; You MW indicat`yes"c r"no"to es►cli of the following for gu inspections Yes No :Backup of u,,w age into facility or system comp®aient due to overloaded or clogged SAS or ce,is; )c i Discharge or pandtng..of effluent to.the,staface orciieground or ssrface.watera due to an overact ic.rd or clogged SA.,c r Xsspool _ Static liquid It ve l in the distribution box above cut let invert due to an overloaded or ceaspool clogged S o :i os' �i liquid depth it cssspool i,,lsss than 6"below invest or svailabl&oluine is less than%x"day fl;tve Required n ng more fl times in the last year�1Q�due to cl0 d or obstructed .,,�!+atb:r ®ftiasea pualp!p,w - a ,;b,u,. pipe(!,,). AMY portion of the SAS,cees:apool or privy is below high ground water elevation. . My portion of Cesspool or privy is within 100 feet of a surface water w supply. supply or tributary to,a au!.1 ia.e Any portion cif is roaspool Or privy is within a ZOM 1 of a public well. Any portion of it cesspool()r privy is within SA Sari of a private waters 1 well. Any portion of t!cesspool car privy is lean tLan 100 iiset but supply supply well vri sh no accaptahle water greater then SO feet from a private wit,is supplperfottined at t no s eert ablefied laboratory,qud*tanalysI .{This system passes if the Well water sane 1 psis, fbr eagifi rin bacteria and volatile organic,colgFoull h 1 12 dicates that the well is!'rase*OW.pollution MOW that facility and the presence odanasmollit nitrogen and rtltrate altrclen is equa&Lib.or lesas.leans 1 pp,*provided that no other:Watre,;r teria Aft tiriggeeed".it copy of tlMs analysis newt be altaiched io this dorm.] (YesrNo)The systcan fa&1 hsiyv determined that ons:In more of the above failure criteria exist as, described in 3`�l C1 CMR 15.303,thwefare the systmn bits. The sy4t�em owner should contact the 11 s.rd of Health to dertenrisse what will be�censargr to cone};t the failure. E. Lnrge S; . .'fo be considered a large grli:em the s),a � ss�yea bsi a gpd. flow of 10,000 gpd to].;i,dtiFN YOU.must indac:atoe either`S l.its'"'or'Int+s eaeh.6ftihe blliow►isag; ("The following;criteria appe G� syn,teena In addhim to the cxggria above) yes no the s ta is rn 400 feiet of a surface drinking wzu lr supply the sl►Z`im will.n:200�feet oi'a tributary to a aurface;drinking water supply .� are sis loca:scl in a nkrol-Im sensitive area(interim Wellhead Protection Area—IWPA)Or a in;,,:pal Zo 3 of a publi vbater suppl;r weld ifyOU a answered"yes" jo any quet dc�n in Section E the "yes"' Section,D above tbo1 hIrge sys0om has failed. lie Owner for Operator is considered a significant threak or amm ar 1 si cant tsar'under Sect ozi E Or failed under Section D shall trpg:ade the f any�system considered,a T S 04. The system owner sl;ould contact be O system t m�mdanee with 311, P�rsgiOns 4 office of the Department. 4 i f Page S of l I OFFICIAL I'X WECTION FORM—NOT I"OR VOLUNTARY ASSESSME3.4, ," SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PARILF ]8 CIIECXLIST Property Address: ra' � �� ` '0—. .. Owner: Date of Impeetion: Check if the.following bake been done.You mast indicate"Les„or"no"as-to eacb of the foil® Yes No . _ _ F'oureging information was provided by the owner, ccsupant,or-Board of Health ._ Were-any of rh r system components pumped out in the previous two weeks ? Has.tbe syste,n;received norinal flows in the prey' "two week period? Have large`Ve4irmes of water been introduced to die sy stem recently or a.9 part of this inspection': K. Mere as built p l;trts of the sy:atern obtained and exkrsired?(If they were not available note a;i T Was the facility 01-dwell M;inspected for signs of:swap back sap? _ Wes the site uispected for sipps of break out? Were all system eomponems, excluding the SAS,located on site? !� Were the septic tank manholes uncovered,opened, +und the interior.of the. inspected forthe c�;�.dition of the baffles(or tees,matt;ria.l of construction,dimensions,depth of liquid,depth of sludge and depth of scu:c X — Was the facility owner(and occupants if different 1i'om owner)mainte provided.with information on the i ;sp,:r nance of subsurface:s e�vagi disposal systems? ` P.J tJ .r v`t The aAze and 1004033 of the Sall Absorption S to p ys an(SAS)en the site has been deterlained baaaed ;a: Yes no .� Existing infortt.s IM.For example,a plan at the Board of Heshh. Determined in the field(if any of the fsilmv criteria related to Part C is at issue approximation rs Unacceptably.)(310 CAG; 1:5.302(3xb)) o;E'r,i uance r v Page 6 of 11 OFFICIAL INSPECTION FORM-NOT VOR VOLUNTARY ASSESSM&V'I'', - SUBSUES AC'E,SK'AFAOE:DISPO,SAI.SY3'TbdiN*SPECTION FOIi]Vi PART 1C SYSTEM INFORMATION Property Address:,�/ �►'e«a Oweer: Date of Inspection:_.4 FLOW C014DMOPIS RESIDENTIAL Number of bedrooms(duig►t):.Z_ Number of bedroom:i(aotual):,., DESIGN floor,based on 3:.0 CMR 15.,203(for example: 110 g4 x#of bedrooms): X3Q Number of current resid win: Does residence have a 69'*je grinder(:yes or no):/--JO Ilaundry on a separate se'HaLge systo:u( +or'ao):� [if 3,00 separate inspection required]r Laundry system inspected Iyea or no): Seasonal use: (yes or no;: a110 � Winter meter readings,of Akio 'fable(last a years usage(gpd)): 6C) tam Sump pump(yes or no):,(0 � F97 Last date of occupaocy::�t;� COMMERCIALJINDLIS);IitUL Type of establishment: Design flow(based on 310 C:I3 2— *d Basis of design flow(seas I'I x �� ft,stc.): Gram trw p t�CCrKr IndustrW waste holding is present(;►ea or no):_ Non-sankuy warmer di rated to the Title 5 system Water meter r:cad available: (ems or asp): Last date of Co. OTHER( )• __ Pumping Records GENERAL INFORRM)►pcTON Source of information:'pal N o G O C-&p � Was systeas pi ped as pal of°the inspection(yes or up):&77� If yes,volume pumped:-___—gallons How was quantity pumped determined?Reason for pumping: TYPE OF SYSTEM -,Septic tonic,dfItnUftD tlM soil abriurpriaa system _Single cesspool ,W,Overflow cesspool Privy Shared sysrtem(Yes or rr*(if yes,atts,ch pnovious iasapeetiml records,if any) _lnue ovative)"ykh nrative :xamology'Aatach a co of the current y obtained#ruin system owan:) py opera►tion and maintenance contract(tu toe _Fight tank _Attad: a.COPY of this DEP appa;oval Other(describe): Approximate age of all coma onents, date installed(if Imown)imj OpuOLA s Were sewage odors detected wlren arriving at the site J , (yes Cr no); i - r Page 7 of l i OFFICIAL INSPECTION FORM..-NOT FOR VALUNTARY ASSESSMEN 1 SUB3URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR r C b"DSTEM INFORMATION(continued) Property Owner: Date of Inspection: BUILDING SEWER(I*ale on site plan) Depth below.grade:_Z®,_ Materials of construction:_9cast iron 40 PVC�othi r ;explain); Distance fra�m'private vans;r supply wail or suction litre `'" _ Comments i'oa condition of Joints,venting,evidence of leakgv,etc.): SEPTIC TANK: (locate on site jAin) 1 Depth below grade: _ Material of construction concrete ametai erglaas_polyethylene other(explain) _.. _ if tank is metal list age: Is age cean g+a Certificate of Compliance(yes or no certificate) ) ._ (attach a Op!( 3f Dimensions: Sludge depth`~ _ Distance from top of sluallp ro b m of outlet tee or baffle: Scum thickness: _ Distance from top of sawn ' p of ot;1let tee or baffle: Distance from bottom of n)of outlet tee M FM—A- a How were dimensions tsn•ntined:_ Comments(on pum ' g'eccmmendetims, inlet and outlet toe or baffle condition,structural integrity,iic:u4..Iiwcls as related to Hutt ve cr�,idence of!e �'> I�. leakage,etc.): GREASE TRAP:_(lo:aa:m>on site plan) Depth below grade Material of construction: _�oac (explain):_____ --- 1..,_.. s .--Polyethylene other Dimensions: __ ._ , Scum thickness: - Distance from top of�;o•top of Out]tA tee or bade:_ Distance from bottom ac u a to bottom,of outlet tee or baffle: Date of last pump• __ - Comments(on p in&re:ommendatimik inlet and outlet tee �baffle condition, structural integrity,2aquic3:I{ eels. as related to ou.ti invert,evidence of lemlcage,etc,): w Page 8 of 11 OFFICIAL, IiVS PEC 17GN FORM—NOT FOR VOLUNTARY ASSESSMIE'N'l 1, SUBSUI YF 4.CE SEWAGE DISPOSAJL SYSTEXINSPECTION FOIVVI ' PART C SYSTEM 1NFORMA.TION(continued) Property Address: d '4(*a V444r"'1'�G airt �j+c c^Q fy �w iS Owner: _] Date of Inspection: t TIGHT or HOLDING 7 AN1C: (teak must be pumpe ii t time of inspectionXiocate on site plan) Depth below grade:,,__ Material of construction: __,coacret,e me fiberlllass polyethylene other(explaia): Dimensions: --- Capacity: __`gallc►r� Design Row. , al day Alarm prese:at(yes or no►: a_ Alarm level: Alsuat 'ag order(Yes or ao):_ Date of last P pig;um _ -- Comments((:ondition of ¢m and flour swiWhes,etc.): DI§TRIBU"I'IOIV BOX:- (if pr":11t be openedxlo,:;&te on site plea) Depth of liquid level abo`r:outlet' rt Cornrnents(note if box is l;�rel distribution to outlets equal any evidence of solids carryover,any evi.dj=,, : of leakage into or out of box e) , ... ---------- PUMP CRAM R: •{.Ixat site plan) Pumps In wort:Mg order or no):._._ Maims in wot;king o (yes or no): _ Comments(note c ition 4 pump c}a r!iber,condition ofpumlls and appuctanances,etc.): 4 r Page 4 of 11 OFFICIAL.INSPECTION FORM—N01"YOR VOLUNTARY ASSESSMEN';[: : SUIBSUItf,,A.CE SE%!AGE,1`D.ISPOSAI SYSTEM 110PEC'TION FORM PAR r c SYSTEM UffORNLA T ON(continued) Property!►de8rep: �a L c' Date of ftqwdw: - 74 SOIL.ABSOiQP'I;TON SYS'TEM(S.CS): peaeate on elt.-plan,excavation oat required) If SAS not located explabi why: Type leaching pits,number: leaching chambw.w.:uember:T_ leaching galleys,nuatber:_ leaching trenches,aintber,length: leaching fields,number,dimensions: F overflow cesspool.,Lumber. - imovadve/altemwivi:tystern 1'ype/nameoftechnolgjo� Comments(note eonditiote cf soil, of hydraulic failure, bevel of ponding,damp soil,condition of verge:!,rlioa, CESSPOOLS: (ces.7w01 must her pumped as part of inspe+ction)(tocate on site plan) Number and cortfiturati": Depth-top of liquid to i n ItWert: .nth of solids layer: — - Depth of scum layer:�►� '-"--- Dimensiom o.cesspool: _, Materials of constt=. ' Indication of groundwater is w or no): Comments ate conditi ecit°soil,sigi3;e a ydmwic fail ,level of Pending,condition ve o V ._._.. jL (locate on s;te::plan) Materials of construction, Dimensions: Depth of soliei': _ Comments(note condition of :ofhydraulic&UUM10 rol of Podding,condition of vegetation, Page 10 of 11 OFFICIAL Il•IS E,CTION.FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURF'.4 CIE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART 1 SYSTEM DMORMATiEON(continued) Property Address: . Owner: - _ Date of inspection: f ` 4 SKETCH OF SEWAGE WSPOSAL SYSTEM Provide a sketch of the se%nge disposal systern including ties to v least two permanent reference landmarks a:, bencbniarks. Locate all well,; v ithin 100 feet.Locate where public water, supply ebters the building. ' F F I Page 11 of 11 OFFICUL EiS)FECMON FORM'-NOT FOR VOLUNTARY ASSESSME";] SUBSUI31'Ae'M-SEWAGE DISPOSAL SYSTEM INSPECTION FORIA PART C SYSTEM INFORMATION(continued) Property Address:C f Owner: 014vi Date of In!pection: STrE EXAM ( / Slope ' Surface water Check cellar Shallow wells ]Estimated depth to ground water feet Please indicate(check):dl methods usec to determine the hi11h ground water elevation: Obtained from sys mra design p1 ms on record-if checkeit date of design plan reviewed: _aL_Obsweed site(abutting property/observation hole within 150 feet of SAS) Checked.with local I'laud of Health-explain: Checked with local a KcaVatorS,in:.tallers-(attach documentation) Accessed USOS diku&-se-explain: _ You must descri `,�u establi rd e high �e how y lr around wa4tR,r eievatiio i ll . TOWN OF BARNSTABLE LOCATION ''I 01)e ji t, Q `I ,! —SEWAGE # 03 VILLAGE a e . na`SSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ;J(Z0 0 CeSSPOO I LEACHING FACILITY:(type) /vow cgjk 3)c5"ize) _ 06 Cc,14� NO. OF BEDROOMS . PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER\_LM_'PS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes - No c�" .��Y-vf ^` l�\y r V ' (�('� V Ga �� f ®^ �`i .. �� v:o. o No... Fss.._...` Q_.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OyF� HEALTH �1�.IGLU-....OF................[..... .--.-........ - ................................... Appliration for Bigpaaa al Marks Tonstrnrtinn amit Application is hereby made for a Permit to Construct ( ) or Repair X) an Individual Sewage Disposal System ��-ryryat: Yr / �f d ..... _.......... - .......... ...................••-•--...-•-•---•-....._.........--•-•-•---• ••••••----......-••-•____••-•-•-- ocati ddress or No.. .......... x-•- .4_(e(lr�........-............... ��_� �L�4'I l..z_........---•--...------- Ow�per Address a �Ca Jr � P )a PL? 3 ----- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... -_______________ _Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ____________________________ No. of persons Showers — W YP g P ---------------- ( ) Cafeteria ( ) Q' Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_____________ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________--. GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-______________________ x ODescription of Soil....................................................................................................................................................................... x V --•-•-••--••---•-••------•-••-••-•-----•-••••••••---...---•-•-•-•-•--•---••••--•••-••.............•......----•-----••-----•-•••-•--••-----•--•••--••---•-•---•-•-•---•--•--•--•••-...•-••---•••••-•-•••- 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 L!'LE 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 Ward of health. Sig ---------_-------- Date Application Approved B _ Date Application Disapproved for the following reasons-.................-----••----•-------•--•-------------........................................................ ----------Date-------*-------- Permit No......... �? - �.rQ•-3.............. Issued...---•--•---•----- ................................ Date i. Fmc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF................. ..... Applira#inn for Biipns ai Workii Toes rnrtiun Pumit Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal System at: .........L •Locati•n . d..... -_or .. No. ....................•- ..........� ��-�>> •s---- " �li/\Ii ............................ �. i .. �- . ..................... Ow er Address -- ........ Installer Address Q i Type of Building Size Lot----------------------------Sq. feet U F Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons---------- ............... Showers YP g ------------------------•-•- P ( ) — Cafeteria ( ) .. Other fixtures --------------- -----•••--•-•-•-•-•--••---•---------•---••-•-----•••••...._......•-•-------•---•-••--•-------------- --------•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid"capacity............gallons Length................ Width................ Diameter--._..-.-_____-_ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ''~ Percolation Test Results Performed by................ ......................................................... Date........................................ W , Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_.___.-----_-----_._.- f1 Test.Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._--__---_-•_-._..-_-. P4 ---------------------------------------------------------------------------------•---------.....•......----------•-.........-----------•-----•-------••--•-- xDescription of Soil.....................................................................................--------------•------------------------------------------------------••-•-------•- U �:'---------------...............................................................--•------------•----------••--••-----------•-• -••-•-------•-•••-••---•-••----•-------- ......................... W VNature of Repairs or Alterations—Answer when applicable.___..................... f --•- -----•-•-••------•••---•------------------------••----•••------•--••--••------............------------...-•--•-------......-•---•---•--•-•-••---•-•--••••••-•-•--••--•---------•-------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with *.-.e the provisions of TTTLE p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... Date Application Approved B � _ ----------------------------------- ........... ------•? r a Date Application Disapproved for the following reasons--------------------------------•----------------------•-------•-----------------•-----------------•-•--•-------- ..............................••....-•-...•-------------•-•-----------••------•-----..-------------•...----..........-•-•----------------------------------------------------------------------...•----- /� Date Permit No.._.....e.£`.�. ..... .............. Issued_....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......�/ ............OF..................ieo '!..r. `. .........._._.............. T-prrtifiratr of f�nnt �i�anrr THIS IS 00 CERTIFY Tat the Individual Sewage Disposal System constructed ( ) or Repaired (� by..................... Q:`t .....� Jp*ktaller 'Y has been installed in accordance with the provisions of TIT' S of he State Sanitary Code as described in the application for Disposal Works Construction Permit No..-__._ .__. ��:.. .. dated.......................... ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -_ ��//�� 6L. .L...........OF...........(�... �..J.k:!.` 1:`.ry:%"......... ........ FEE '}No.�....-.1........ .......... Disposal nrk � n ;trnrtinn rrmit Permission is hereby granted------- --•----- C..4".......tfm ---••-••••--•-••••....--•-...--••-------•...•--•--......--•........................... to Constructs ) or Repair>') a Ind v'dual�e�rage D' posal System at No.. / �a.- _z.�-,c�� CZA[c Street as shown on the application for Disposal Works Construction Permit No�'4(o3.._ ted.......................................... u � •�, rd of Health DATE_....• .-•-•- �• -� - S FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ,ti 0 No......................... Ftas bJ..'... ... .. THE COMMONWEALTH OF MASSACHUSETTS. BOARD OF H LT ..........of.....8.... .<4 ...C. -.U. . � - Yt Pruiit Appliruttuu fur Ditip utti urkti Towitrur�iu Application is hereby made for a Permit to Construct ( ) or Repair ( ) an IncPividual Sewage Disposal System at: Aor Address A ...I..._No. Owne Address a -. .• _� nstaller Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------------------------------ -- -Expansion-Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow-._--_--_-.......-_-..---------------- _.---gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length................ Width.-----.--....... Diameter-----_ h _.-----... Dept ------------- - xDisposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area-----.-.--.---..-.sq. it. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ---------------------- .......................................... Date-------------------------- ------------ ,� Test Pit No. 1................minutes per inch Depth of Test Pit.------ ..---------. Depth to ground water...---_.--------..___- (= Test Pit No. 2................minutes per inch Depth of Test Pit..-..-.-...__-_--_-. Depth to ground water------------------------ -----------------------------------------------------------------------------------------------------•---------=------..-....-------------------------------------------..................................................................... ODescription of Soil----------- --------------------------------------•----------...--------------------------------•---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- w ----- - - ......- - --------- -- U Na ure of Repairs or A lte a ions—Answer when app ca ' / . `?.. f �-� .!� --------------------- ----- greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee issued by the boardZhe . Sign - � C ----�-.-� •-� Date Application Approved By------ — _• ••. - ---------------- --_- ' z-Z'7�------- Date Application Disapproved for the following reasons:--•---••---------------------------------------------------•-----------------......--_----•-----•-•-•......----- ---......•--•-•---__-•....•--•--•••••-------•-----------------•--•--•......_•-------•------•--•----••---•---------•-•-----------------------•--•----...-..-----------------------------•-------------- Date PermitNo......................................................... Issued.....---- ............................................... Date -TU.. ................. Application is hereby made for a Permit to Construct or Repair '-)—an A7Mn widual Sewage' Disposal System at: I Address or Lot No. Address nst Ile; Address Z Other Distribution box ( ) Dosing tank ( ) U .... .�t�! .......0.r"---0__ V ------------ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has,, en issued the board o�Ze ------------ -- .. ... ------(7--------------------- 1,4��I,��Ia_.,4,1p�----------_------_ ..... ------ Application Approved By------- Date Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH THI JS T E Y, TI t the I vidual Sewage Disposal System constructed or Repaired has been installed in accordan the provisions of Arti%XI of The State Sanitary Cod as dZ__�_eiin the application for Disposal Works Construction Permit .......... dated........... ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ----------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD H THE COMMONWEALTH OF MASSACHUSETTS Permission is hereby granted---------- - --------ff 124z _J� ....... .... ................................. ....................... ''---'r--------�----`-''--`--- -' ----.....—�-'-'-------------'--'--'~ ~— ---'--+''--'-''— �� as shown oo the application for Disposal WorkyConstr � —'--''v---------'-~Boar of Health ------'- DATE...........-� �° ~ �� ^� �^ ` .—.-----' �_----------.----_ runw 1255 x000smWARREN. INC.. puaua*cns