HomeMy WebLinkAbout0026 GRAYTON AVENUE - Health 26 GkAYTON AVE , ;HYANNIS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form,
5ubsurtace Sewage uisposai bystem Form -Not for voluntary Assessments
26 Grayton Ave. �-
Property Address
Pemberton
Owner infnrrnatinn .. .
is required for
every page. Hyannisport MA 02601 . 3/28/18
City/Town State Zip Code Date of Inspection h
0
Inspection results must be submitted on this form. Inspection forms may not be altered in ny
way. Please see completeness checklist at the end of the form.
A. General Information 51 1 �Z
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certifv that I have personally inspected the sewaae diSDosal 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
sewaqe disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
IRI Passes F C nnditinnally Passes n Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/28/18
lnspectbrrs Si natur Date
The system inspector shall submit a copy of this inspection report to the ADDrovina Authoritv(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
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Commonwealth of Massachusetts
: Title 5 Official Inspection Form
subsurrace sewage Uisposal System form-Not for voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
is required for every page. HY P annis ort MA 02601 3/28/18
_
Citv/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. Insoector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I r.Prtifv that I have nar.,nnally in.,nPrtPri the.,awanP rii.,nn.,al.,v.,tam at this wirirP.,.,and that tha
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
sewaae disoosal systems. I am a DEP aooroved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
M pnccac n rnnelitinnniki Pnccac M Pnilc
❑ Needs Further Evaluation by the Local Approving Authority
3/28/18
Inspector's Signature Date
Tha Svcta...m in..cnar..tnr.,hall .,uhnnit a r.nnv of thi-, insnpntinn rannrt to tha Annrovinn Ai rthnrity(Rnard
of Health or DEP)within 30 days of completing this inspection. If the system 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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 3/28/18
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:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/28/16 .
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 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.
l5ins.doo•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. HY P annis ort MA 02601 3/28/18
City/town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
7 bedroom home had 4 bedroom system installed in 1993. 4 bedroom based on permit and verified
as 4 by Health Agent. There is no engineering on file.
The septic tank and D-box are of H-10 construction and not designed for vehicle loading
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):
i
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 3/28/18
Citylrown 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):
i -
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if .
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 3/28/18
Cityrrown 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
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 Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 3/28/18
Cityrrown 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.
I
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
-❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
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.
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. HY P annis ort MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): n/a Number of bedrooms(actual): 7
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of W
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. HY P annis ort MA 02601 3/28/18
City/Town State Zip Code Date of Inspection
j D. System Information
Description:
4 bedroom permit 1993 on file
Number of current residents:
0
Does residence have a garbage grinder? ❑ Yes ® No
i 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: Seasonal
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/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: No pumping per owner
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. HY P annis ort MA 02601 3/28/18
-
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:
1993 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 septic tank appears to be structurally sound
If tank is metal, list age:
. years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
3"
t5ins.doc-rev.6/16 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
w 26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for p
every page. y H annis ort MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
11
Distance from top of sludge to bottom of outlet tee or baffle '12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
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.):
Pumping suggested every 3 years to prolong the life of the system
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.doc•rev.6/16 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
26 Grayton Ave.
lug -
Property Address
Pemberton
Owner information Owner's Name
is required for
every page. Hyannisport MA 02601 3/28/18
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:
i
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
I
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hyannisport MA 02601 3/28/18
Cityfrown 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, 01.
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.):
D-box is 18" below grade and in average condition for its age
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:
l5ins.doc•rev.6/16 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
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for p
every page. y H annis ort MA 02601 3/28/18
CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5
❑ 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.):
5 infiltrators per BOH record. The infiltrators were video inspected and are dry at this time, bottom is
approximately 3' below grade, no indication of past backup
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.doc•rev.6/16 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 Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hyannisport MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
j Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for p
every page. y H annis ort MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ins.doc•rev.6/16 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
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for Hyannisport MA 02601 3/28/18
every page.
CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>12'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Site is on 60'contour
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
r
t5iris.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17+
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Grayton Ave.
Property Address
Pemberton
Owner information Owner's Name
is required for every page. Hyannisport MA 02601 3/28/18
Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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CO\1_%10\-t'EAL,TH OF MASSACHL=SETTS
_ ExECUTIVE OFFICE OF EXVIRO'.NMEN TAL AFF.AIP.S
= F DEPARTMENT OF ENVIRONMENTALTROTECTION
ONE '"INTER STREE':. BOSTON KA 0210r t617i 292-5500
TRL DT CO\E
Secre:a_-*-
ARGEO PALL CELLUCCI DAVID B STP. 'HS
Governor Com.-nissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION
Prop"Address:26 Grayton Ave . NameofownerJessie Sentner
Hyannisport Address of owner:
Date of Inspection: S_I--7-0--
Name of Inspector:(Please Print)Wm. E . Robinson Sr .
1 am a DEP approved systerq inspector p+rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Jeptic Service
Marling Address: PO Box 0 9. Centerville . MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sews e disposal systems. The system:
_Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: .<,X 2_— Z-0
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
t IN'1.0 � .1 200®
revysea. 9/2/9S page Iorn
I_ n
- i• = ^red on Rea•drd Panr, -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A ,
CERTIFICATION(continued)
'roperty Address: 26 Grayton Ave . , Hyannis port
Ownw: Jessie Sentner
Date of Inspection: .5_�?_1)—.0 _0 _
INSPECTION SUMMARY. Check(AJ B, C, or D:
A. SYS PASSES: ��
I have not found any information which indicates that�any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. ` YSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y s, no, or not determined(Y. N, or ND).' Describe basis of determination in all instances. If "not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or-obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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revise-6 9/2/98 Page 2ofII
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i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icontnued)
Property Address: 26 Grayton Ave . , Hyannis-Dort
owner: Jessie Sentner - ti
Date of Inspection: .S•'a 7— C&-tJ
C. FU ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
pu lic health, safety and the environment.
1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) YSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
reviser 9/2/98 P2ge3of11 4.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION (continued)
Property Address: 26 Grayton Ave . , Hyannisport
Owner: Jessie Sentner
Date of Inspection: 0 0
D. SYSTEM FAILS:
You mus indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
termination is identified.below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes N
Backup of sewage into facility-or system component due to an overloaded orclogged 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 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
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E. LAR E SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
he following criteria apply to large systems in addition to the criteria above:
he system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone 11 of a public
water supply well)
The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of t e Department for further information.
revised 9/2/98 a. Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Prop"Address.: 26. Grayton Ave . , H,yannisport
Owner: Jessie Sentner
Date of Inipect,on:
Check if the following have been done: You must indicate either "Yes`jor "No" as to each of the following:
Ile
Yes No
Pumping information was provided by the owner,occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
The facility or dwelling was inspected for signs of sewage back-up. e
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
V _ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.N.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(1.5.302(3)(b)]
_ The facility owner (and occupants,if different from owner) were provided with information on the propermaintenaacii-0f
SubSurface Disposal Systems.
' revise ri 9/2/9'8 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
►roperty Address: 26 Grayton Ave . ,. Hyannisport
Owner: Jessie Sentner
Date of Inspection:
FLOW CONDITIONS
j RESIDENTIAL:---
Design flow: �.t��1g.p.ddbedrnnm.
Number of bedrooms_Idesiq�l: Number of bedrooms (actual):7V
i Total DESIGN flow_- -
Number of current residents:
Garbage grinder(yes or no): /1.0
Laundry(separate system) (yes or no�; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): 4 q 9 t/
Water meter readings, if available (last two year's usage(gpd): 7 9
Sump Pump(yes or no):A "v
Last date of occupancy:a�-27—•G+-c) 7`1 �7a-25 /
COMM CIALIINDUSTRIAL:
Type of tablishment:
Design fl gpd 1 Based on 15.203)
Basis of d sign flow
Grease tra present: lyes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m er readings, if available:
Lastdat of occupancy:
OTHE :(Describel
Last to of occupancy:
GENERAL INFORMATION
PUMPING RECORDS an source of information:
System pumped as part of inspection: (yes or no),�,o
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
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)
IIA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other. s
APPROXIMATE AGE of all components, date installed(if known)and source of information: � •
Sewage odors detected when arriving at the site: (yes or no)
revised G/2/9E Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddress: 26 Grayton Ave . , Hyannisport
owner: Jessie Sentner
Date of Inspection: t--7—
BU DING SEWER:
(Coca on site plan)
Depth elow grade:_
Materi of construction:_cast iron_40 PVC_other(explain)
Dista a from private water supply well or suction line
Die ter
Comm nts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan) t
9
Depth below grade:
Material of construction:vconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_!- Wage confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: 0
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: �/g
Scum thickness: 0/ . I
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom 91 outlet t or baffler
How dimensions were determined:
;omments:
(recommendation for pumping, co tion of inlet and outlettees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence leakage etc.) 7-J— ) G L
A 1 /�i d �� S•-.
GR SE TRAP:
(locat on site plan)
Depth b low grade:_
Material t construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimension
Scum thick ass:
Distance fr m top of scum to.top of outlet tee or baffle:
Distance f m bottom of scum to bottom of outlet tee or baffle:
Date of is t pumping:
Comme
(recomm dation for pumping• condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence f leakage• etc.)
rev—J sed 5/2/98 Page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
,roperty Address: 26 Grayton Ave . , Hyannisport
Owner: Jessie Sentner
Date of Inspection: 6 -ri k
I
TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth b ow grade:_
Material f construction:_concrete_metal Fiberglass_Polyethylene_other(explain)
Dimensi ns:
Capacit gallons
Design ow: gallons/day '
Alarm resent
Aler level: Alarm in working order: Yes_ No
Dot f previous pumping:
Com nts:
(condi ion of inlet tee, condition of alarm and float switches, etc.)
t ,
DISTRIBUTION BOX:V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,v(dsnee of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CH MBER:_
(locate on ite plan)
Pumps in orking order: (Yes or No)
Alarms in orking order(Yes or No)
Comments
(note con tion of pump chamber, condition of pumps and appurtenances, etc.)
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revised 9/2/98 Page 8or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
4op"Address: 26 Grayton Ave . , Hyannisport
Owner: Jessie Sentner
Dane of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits; number:_
leaching chambers,number:
leaching galleries, number:_
leaching tenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
Incite condition of soil, signs of hydraulic failure, level of ponding. damp soil, condition yf ve etation, et .)
1 b k c !L '-� G y... b '✓x S e e/ ci s d L s
11Lt/
CESS LS:_
(locate o site plan)
Number an configuration:
Depth-top o liquid to inlet invert:
Depth of soli s layer:
)epth of scu layer:
Dimensions o cesspool;
Materials of ci instruction:
Indication of c roundwaler:
inflo ov (cesspool must be pumped as part of inspection'
Comments:
(note condit on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY
(locate site plan)
Materials of construction: Dimensions:
Depth of olids:
Commen s:
Incite co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
ev_se: J�L,'7C Pagc9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(corrtinued)
Nop"Address: 26 Grayton Ave . , Hyannisnort
lwner: Jessie Sentner
Date of Inspection: ✓ D--V
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS'topt,Address: 26 Grayton Ave . , HyannisporpON(continued)
Owner: Jessie Sentner
Date of Inspection: f a7^/_O—J
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow.
Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater-O
Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
/Determined from local conditions
`Z Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
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.revise,:. 912198
Page 11 of 11
CG TOWN OF BARNSTABLE `
LOCATION SEWAGE #
VILLAGE A�j �, Q ASSESSOR'S MAP & LOT M` 0314
INSTALLER'S NAME & PHONE NO. �\�� �� -im (,O ZBq
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) UOROXrO (size) 7 X
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ae-Liva-
5
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ��
�.,. Z�g
�- T 7 Q ,r CSf
f
xs-
. y�va
73 APPROVED
Ngarn.stab-e-ConservatiOn Deparment /FEic........... . .......
THE COMMONWEALTH OF MASSACHUSETTS
Signed Date A R D OF HEALTH
TOWN OF BARNSTABLE
Appliration for Biopooul Worko Tomitrurtion Permit
Apaco..plication is hereby made for a Permit to Construct ( ) or Repair ( �n Individual Sewage Disposal
System at
... 9.
-•---•----• •--•-•--------------••-••................................................................
-•••••^
1d c or Lot No.
c - ..............
Owner /�/� d s
w . -•
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.................----------- Showers ( ) — Cafeteria ( )
a Other fixtures _______________________________ _ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid'capacity_.......____gallons Length:............... Width................ Diameter---------------- Depth................
x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.........................
(i, n Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p; ................................•-•-----...............••-•-•...................•-•-----•-••.................................................................
0 Description of Soil-`........................................................ --•-•-----•--•.........................•••----------•--•-•-•-----•----•-•-----.....---•--•......-•••......
W -----------------------------------------•------:---.......-----------..........._..--•------------------......-- �j� -------•-----•-------•-•-•-----•----....
x Natur f Repairs o Alterations—Answer when applicable...__..�.a.lVO.
U , _ PL "u
..t.V ----- ----------------•---•---------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environ tal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ee issu a board of health.
Signed ....... ......... ...................................................................................... .................................:......
� Dare a
Application Approved By .............C�e. ,...' .,1. .,•. •-. ........................................................................ ../.�.-.�. ..."../... ...
U Date
Application Disapproved for the following reasons: ........................................................................................................................................
.............................................................................. .........................:..................................................................................................... ........................................
// Dace
PermitNo. ......9. ........1.?. ...!..................... Issued ....................................................................
Dace
_ � 7
A!,
yr�r,��� '� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f
TOWN OF BARNSTABLE
Appliratinn fur Di-nVnuttl Wnrk.6 Cnunutrurt"inn rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Ll"an Individual Sewage Disposal
System at. �� . \`
,r
.. .. v�: : .............................................•••-•..............----
c \d (e -------- or Lot No.
Owner ddr s
�.
a ---- .. . �1 + �-----------------_- :_. S�Y4�a-��\��.... '!'���....... •'.-'-. =
Installer Address
UType of Building �,/ Size Lot............................Sq. feet
..� Dwelling— No. of Bedrooms---------....................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building ........ No. of persons............................ Showers
g ---------=--------- P ( ) — Cafeteria ( )
QOther fixtures ---------------------------------------------------------------------------------------------------------=--------------------------------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .......A�._.._.._. 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........................................
Test Pit No. .1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L% Test Pit /No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptiont'of Soil................................;-----------------------------....----------------------------------------------------------------------------------------....--•-.-----
x .-
w
..
-------------------
U Nature_o Repairs or Alterations=Answer when applicable---.---.
. 4v..--� .. ..�...:_.�� ------------------------------•-----------------------------------------------------------•--------------------------------•------••-------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environm tal Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce k�a ee issu e board of health.
Signed ....... .......... ..............:...........................................:............................ ..........................................
..
Dare
Application Approved By .............CJ ..C. 7.......................................... ........................... ..f -......3......c/.._�'�....
Dare
Application Disapproved for the following reasons: ........................................................................................................................................
..........................................:..................................................................................................................................................................... ........................................
`—... Dare
Permit No. ........... ...
................ 6.>.................... Issued ....................................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(9Er#tftra e of C90mft_lttnce
THIS STQ.CERPT_Y--j at the Individual Sewa_e Disposal System constructed ( ) or Repaired
by ................... (..R..\ -. ....... 1 ................................................................................................................................
• Invallcr
at ........... ,p.. .. .. ... .. 1..... ....... .................
C •�.... i.�4� ........ ... C .............. .....................................................
has been installed in accordance with the provisions of TITLE 5 o Mtate Environmental Code as described in
the application for Disposal Works Construction Permit No. ......... .-...' ..7.8..... dated ...............................................
THE ISSUANCE.OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ��
:. DATE.................................f..r7..�... �.J_ ..h.. .... .... ...... Inspecror .....................�.�......( - ......................................................
---------------------------- ---------------------------------------------
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
q TOWN OF BAR
NSTABLE No... _.-�.t�,� FEE....—��.�.......:
3�iu�ns , 1 nrk��.�nutritr#inn - rrmt
Permission is hereby granted. ��'....----- - - '1 ��!_> -------------------------------------------------------
to Construct ( ,,or Repair an Inds dual Sewage D�imosal System
at No...!Aa _n...... �� .� ......... -�'�" C' ----
Stre / ,�/
as shown on the application for Disposal Works Construction-Permit No.�14055 Dated..........................................
1 _
DATE.......... --- ---- ---1-1-1•--3--•-------......------
Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS