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Home My WebLink About0398 LINCOLN ROAD EXTENSION - Health 398 Lincoln Road Extension, Hyannis =A_ i I Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 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. Important:When filling out forms A. Inspector Information 1, sq-4- on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road to ,� Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2 _. /2020---- 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext V Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This 5 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding leaching pit with stone. At the time of the inspection the leaching was dry and no visible failure criteria was found. 2) 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 FIND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Il; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis annis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 n Y2 than / day fl ow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is Hyannis MA 02601 06/08/2020 required for every H y < page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail: see attached Sump pump? ❑ Yes ® No Last date of occupancy: 3 months ago Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n ,r,� Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext u Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 33"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c V � 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the bafle was in place. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext u— Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts �v Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. The newer H-10 D-Box has riser installed. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ,t� Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ' Commonwealth of Massachusetts �n ,T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding;damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and no visible failure criteria was found. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 398 Lincoln Road Ext V� Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of''Massachusetts Title 5 Official Inspection Form manta Subsurface Sewage Disposal System Form -Not for Voluntary 398 Lincoln Road Ext Property Address Au usto Netto_an,d Jessica Tatara Iwner Owner's Name. —� MA 026_ 01 06/08/2020 rf uiredon is . • H annis State Zip Code Date of Inspection squired for every cityrrown .age. D. System Information (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposalII wells within 100iftities.to at least two public waters supply enters landmarks or benchmarks. Locate a the building.-Check one of the boxes below: hand-sketchh,in th'e-area below ❑ drawih(attac FAhseparately s-Built from the installer attached on next page** r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 of 18 t5insp.doc•rev.7/2812018 6/9/2020 Assessing As-Built Cards L 0 C A T 10 N 2�i ' 'S'Eyi1JA 6 E PERMIT NO. Lc^7 41 L/ Goar� `PD VI ILAC E INSTALLER'S NAME A ADDRESS tlErVfIti0 tl/LOS =iuC N BUILDER OR OWNER L4—- 6ulFr DATE PERMIT ISSUED DATE COMPLIANCE ISSUED C ! 1 d�tt �4c qri W . 0 4' f https://townofbarnstable.us/Departments/Assessing/Property_Values/H Mdispiay.asp?mappar=271032001&seq=1 1/2 Commonwealth of Massachusetts p Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form +_ �i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 398 Lincoln Road Ext Property Address Augusto Netto and Jessica Tatara Owner Owner's Name information is required for every Hyannis MA 02601 06/08/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Date: 6/9/2020 Meter Reading History Page 1 of 1 Customer# 602079-2 Premise#602079 Service:Water-Regular Metered METER READING TRANSACTION INFO Read Date Sequence# Meter# Face Sort # Read Code Reading Consumption Skip Count Type Code Status Bill Period Trans Date 04/20/2020 01 36029826 0 24040510 1 375.00 17.00 0 REG A R 202002 04/21/2020 01/21/2020 01 36029826 0 24040510 1 358.00 35.00 0 REG A R 202001 01/27/2020 10/21/2019 01 36029826 0 24040510 1 323.00 41.00 0 REG A R 201904 10/28/2019 07/15/2019 01 36029826 0 24040510 1 282.00 45.00 0 REG A R 201903 07/22/2019 04/15/2019 01 36029826 0 24040510 1 237.00 31.00 0 REG A R 201902 04/21/2019 01/22/2019 01 36029826 0 24040510 1 206.00 33.00 0 REG A R 201901 01/28/2019 10/24/2018 01 36029826 0 24040510 1 173.00 69.00 0 REG A R 201804 10/29/2018 07/10/2018 01 36029826 0 24040510 1 104.00 55.00 0 REG A R 201803 07/15/2018 04/03/2018 01 36029826 0 24040510 1 49.00 28.00 0 REG A R 201802 04/12/2018 01/04/2018 01 36029826 0 24040510 1 21.00 21.00 0 REG A R 201801 01/15/2018 10/05/2017 01 36029826 0 24040510 1 0.00 0.00 0 REG A R 201704 10/15/2017 09/12/2017 01 36029826 0 24040510 1 0.00 0.00 0 REG A S 201704 09/12/2017 09/12/2017 01 60199249 0 24040510 1 959.00 0.00 0 REG A O 201704 09/12/2017 07/06/2017 01 60199249 0 24040510 1 959.00 0.00 0 REG A R 201703 07/13/2017 Ic0 r\ No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLatlon for ;Disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(L<U—Pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location gdr;ssorLotNe.,?FF- 4,I,ea%r, ,,.+- Owner's Name,Address,and Tel.No. Assessorarcel - 2-- 0 Installer's Name,Address,and Tel.No�C F 3C,'c� � "" 'r7 Designer's Name,Address,and Tel.No. Se,,,j' ,,-k 4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank l d(� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �� C� /-?'b Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the s s operation until a Certificate of Compliance has been issued by this Board of Health. fSi / Date Application Approved by Date 7 Application Disapproved by Date for the following reasons Permit No. ZVZC� %'� Date Issued No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓' Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for Misposal *pstetn Construction 3perm t Application for a Permit to Construct( ) Repair(po*Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location d ress I. �1- or Lot Nd. r Owner's Name,Address,and Tel.No. S� L , Assessor' a ecel co#O (,C ((S46 Installer's Name,Address andfTel.Nop ,5Y q� Designer's Name,Ad ress,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title p ti Size of Septic Tank 00-0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the s�operation until a Certificate of Compliance has been issued by this Board of Health. -5--G'r ? Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� _ /�h Date Issued „ --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS � n Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( > " Upgraded( ) Abandoned( )by �,� c�aUp. D f'w.., f g, ..A Pr fit+ at g ,;. o has been constructed in accordance With the provisions of Title 5 and the for Disposal System Construction Permit NoZan- 17,C dated - Installer ;.A E ;�/ R Designer #bedrooms ?t Approved design flown C) gpd The issuance of this permit shall not be construed as a guarantee that the system wilr7 , V r d ise gned. Date o v Inspector ,, w .. ----------------------------------------------------7------------------7---------------------------------------------------------------- No. E r Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6p$tem Construction permit Permission..is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at S� / �„ ,�, 4! ® '7 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this perm' . Date �/ ��n'Jf1 Approved by � COMMONWEALTH OF MASSACHUSETTS 8 EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL PR O ONE WINTER STREET, BOSTON MA 02108 (617)292 fCEIV�� o Y WILLIAM F.WELD 9 1997 COXE Governor ,0 ARNSTgg(f ecretary DEPT ARGEO PAUL CELLUCCI DA STRUHS Lt. Governor mmissioner t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n L `/ CERTIFICATION /' Property Address: Li K J" ft"/ Ix t7V�k w` Address of Owner: & f�k ce-J— T#Q jU_V_�jE7 G/Z 6 Date of Inspection: O Z - rj (If different) Name of Inspector: Company Name, Address and Telephone Number: 'f�<LP+wITI� EN��e.v+�.v.�.�.:�.h� �•O�cw a��`1t `�^5r�-t-t t`\ra. oZt.�.`\ CSu`G� y77-\tiZa CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails p� Inspector's Signature: Date: c �zbc{a The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection.. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 A i� Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A * f \ CERTIFICATION (continued) Property Addless:1lO Owner: 4/' FK-^xtG 0 S Date of Inspection: \B]`SYSTEM CONDITIONAL'` ASSES (continued) ; ; , � . wSewage backup or breakout or high static water level observed in the distribution box ' due to broken or obstructed @" 6ipe(3),'56 due to a broken, settled or uneven distribution box. The system will pass ' spection 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 r obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of H alth in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI S THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface ater Cesspool or privy is within 50 feet of a borderjng vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and 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• 3) OTHER / 2 (revised 11/03/95) k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f� CERTIFICATION (continued) Property Address: Owner: !Y Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure cr'eria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be conta ed to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an ove oaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or urface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert ,ue to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or av ilable volume is less than 1/2 day flow. Required pumping more than 4 times in the last year N T due to clogged or obstructed pipe($). Number of times pumped _. Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 f et of a surface water supply or tributary to a surface water supply. Any portion of a-cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 5/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. /heII has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic cds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systemson to the criteria above: The system serves a facility with a design fl w of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environm nt because one or more of the following conditions exist: the system is within 400 feet o 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 rtrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system hall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3`f - Owner: tl'- Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and 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. �jAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. l The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3y ; 4 a—,,, Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 33C eallons Number of bedrooms:O''J Number of current residents: CA Garbage grinder(yes or no): 1Q Laundry connected to system (yes or no): Seasonal use (yes or no):j9Q Water meter readings, if available: $30 Last date of occupancy: ^fzz� _ COMMERCIAL/[N D USTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING,ECORDS and source of information: ST'�`q\ Nc S B?w%QtNC4 1 rJ ` sky. System pumped as part of inspection: (yes or no)_tao If yes, volume pumped: rtallons Reason for pumping: TYQ� 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: k0K`�S Sewage odors detected when arriving at the site: (yes or no) C] (revised 11/03/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6"'C_C4 41 /C r/. c/u.Kcoo . Owner: 7 �e&_AT 0SS/ l Date of Inspection: SEPTIC TANK: C� (locate on site plan) Z�f. Depth below grade:1_, Material of construction: concrete _metal _FRP—other(explain) Dimensions: MIJ & Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet i vet rt, structural integrity, evidence of leakage, etc.) 4 l akk a 6 r�1�Zd,1� tuavv 1 To t-z c c GREASE TRAP:)( (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �' —�K c /- . yu� Owner: Date of Inspection: TIGHT OR HOLDING TANK:�� 4 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX. (locate on site plan) p Depth of liquid level above outlet invert: �Jc�l Comments: note if level and distribution is equal, evi ence of solids carryov evidence of leakage into or out of box, etc.) v l� PUMP CHAMBER:—jL3D (locate on site plan) Pumps in working order;(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,Q SYSTEM INFORMATION (continued) Property Add e s: � - .'.c �!r� /ems! - !-- Owner: Date of Inspection: a4le-r ,v- SOIL ABSORPTION SYSTEM (S S):4(5 (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (not c nd tion of soil, signs of hydraulic failure, evel o ponndin coq4ition of vegetation,et4) C O " CESSPOOLS: 00 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:l (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ? SYSTEM INFORMATION (continued) Property Address:J ��K A Owner: �/ Date of Ins tio &4"A2 c G�c'S Si SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' $ Z. 2� 3-1 6Z_ 300 br-7- 36 DEPTH TO GROUNDWATER Depth to groundwater: .20 feet method of determination or approximation: u,, (revised 11/03/95) 9 LO CATION � � ' � AGE PERMIT NO. _ L-o 1 1 L/iuCa v- jeo V I L L A C E I N S T A LLER'S NAME & ADDRESS 11 E row /A-o AIz-oI Z, c- 14 2 B U I L D E R OR OWNER +�- 6 u,I F7- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED -P4 No ........� -- ' Fins....................%..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........1. .w�...........OF.....Z... ......................... 01rc2 03 .1 Appliraffo a far Dispog al IV orks Tonstru.rtion ramit Application is hereby made for a Permit to Construct (,-)—or Repair ( ) an Individual Sewage Disposal System at: y S ...G` 'I ?G'-`!.........................T....-p-�.--- ........ .........................r-o�:�....r......................-----------------......--------. �......... ati�- �s� l ��Sl.::[-or_0 �v OpIror Address 1�. r 12, / /Z r� --•-•-----------------•-----•- •--•----••----------......-----,+ -.. -- z � Installer Address d Type of Building Size Lot_._.__�__1.._, .......Sq. feet Dwelling—No. of Bedrooms........................3 .................... Attic ( ) Garbage Grinder ( ) '_l Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------••-----•--•------------------------•---••-- -• -- W Design Flow...........J .......................gallons per person per day. Total daily flow............. ................gallons. WSeptic Tank—Liquid capacity l0oo gallons Length..19`.... Width. A/f .. Diameter................ Depth 4: .i x Disposal Trench—No..................... Width...- ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./.......... Diameter......t Depth below inlet.....G........... Total leaching area..�....sq. ft. ZOther Distribution box ( ) Dosing tank ( )Percolation Test Results Performed by._.. _ Gs ..%�� 1 q ..,......%................. ------ Date_ � L2 Test Pit No. 1..G.Z..minutes per inch Depth of Test Pit..../ ..`..... Depth to ground water______ ______________ (i Test Pit No. 2..:.............minutes per inch Depth of Test Pit-................... Depth to ground water........................ a -•----•--------------•-•-•-••--.........••••----•........----------•-....................-----------......................................................... 0 Description of Soil---- -��-'.3Z W,9.0j??4t ._ �Su13�So� 3z��- ¢�! s....'J2S ✓� 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 TIThL 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. i d --------- t ApplicationApproved By . --•••- ............................................................................ � p�----- ---------- Date Application Disapproved the owing reasons:-----•--------------••-•----•-••----.•...--------------•-------------.......................................... ...................................... ---- ..................................-..................................................................................... .................................. Date PermitNo......................................................... Issued....................................................... Date No... y... ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFa#inn for Dispnntt1 Workii Ton.strnrtinn famit Application is hereby made for a Permit to Construct (+.-T or Repair ( ) an Individual Sewage Disposal System at: Locati0n'tAtddfes5` r Lot No. W Owner Address ..................................................•----.....-•----............................... ........._.....--------................•----.........••---•............---?-.....---^Q.......• Installer Address f UType of Building Size Lot.ZS 1.-�I..........5 feet Dwelling—No. of Bedrooms.....................--�.......................Expansion Attic ( . ) Garbage Grinder ( ) aOther Other—Type of Building __.____.....•............... No. of persons....._..............___.._._ Showers ( ) — Cafeteria fixtures . W Design Flow...........%-�..............•.....•..gallons per person per day. Total daily flow_._..._.....Z 0.................gallons. W Septic Tank—Liquid capacityl_�p�..gallons Length 8._`�''... Width4`."".___ Diameter________-__•--.- Depths=.` ".". x Disposal Trench—No..................... Width....._._.. Total Length.................... Total leaching area...............--___sq. ft. Seepage Pit No--------/.......... Diameter-----1.0-"_-_•__ Depth below inlet.... .......... Total leaching area.Z,67.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ _ " Percolation Test Results Performed by._. :` �* � _._.. .�. G t'- ........ Dated !°^�'�=-_! Test Pit No. 1.<'__ ___minutes per inch Depth of Test Pit_...f o_'r._._ Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •---------•---------------------------------------------------------------------•--•-•-••--••--•----.........................................................O Description of Soil.... `Wiz... l la�l r .;ram s,r< - .!C" 9 u �f l-'r��'� :5 _.... 5.�+,rA x „ w ...........................................................•---••••---•---•----•---•---•---------•----- UNature 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 TITA 1E 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. .M. Si ed. - -------------------•-..•-• ..........._ ----- '" Application Approved By--- - ---•-- --•--•-------------------------•------------------------•----------- _ ..�...�._.--•----------- i Date Application Disapproved th '. owing reasons----------------------------•---------------------------•----------------------------......................... •---------•-----------------------._........------..............................•........................-•-" ..---•......-- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............�,k1.a/.........OF........,�5;�T .........................•...-• OurrfifirFa#le of TnntpliFatta Ty CERTIFY, That the Individual Sewage isposal System constructed � or Repaired ( ) by----- -- -- ---------------------------• ................- -------------.------------------------------------------------------------------•------------< Ins 17er i at -----=-- ---•--•-/--••-------.... = �xa.::_:_ = -------------•-----••---•---••••--•••-••-----•-•-----••••-••--......------.............._............•... has been installed in accordance with the provisions of � R r f 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. 4 DATE........................../�, '�.�.`. .�........................ Inspector............. 2 -•1111 i- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH {f .f!'f ....O F...... st..�.5 ' e. ---... No.. '..r 7� f.—c:.............. FEEd...................... Disposal Workii Tnnstrnrtinn ramit Permissionis hereby granted............................................................................................................................................... to Construct V1 or\Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the/apicatio for L:sposal Works Constructione 'i` ' •..... -------------------••-••.--•----------------•-•--•••-•--•••----•------.......••-_...._ Board of Health DATE.. • ..;_6 <— -------------•------------------------•-------- FORM 1255 A. M. SULKIN, INC., BOSTaW . 2� 19 z � of . Ni r 3 0 v v Lo T I , 9� o�� A o -- •R' CERTI FI ED PLOT PLAN LOCATION . . � /.�ll�.��. . SCALE . �. ��=.-3a DATE ..8 /. PLAN REFERENCE . ...4?r�1 . . ..�T'"! . ,?•moo w.v v Al ��aVSM OFA��s /�6'• . . . . . . . . . . . . . . . . . . . . . . . . . . . . EDW R q�'S LLEYrni No Z6100 H I CERTIFY THAT THE !S?/�� 411Dg�'�0� SHOWN ON THIS PLAN IS LOCATED ON THE GROUND �r'�STEP oo � AS SHOWN HEREON AND THAT IT CONFORMS TO THE �NoauavE� SETBACK REQUIREMENTS OF THE TOWN OF .WHEN CONSTRUCTED. �(�(J DATE REGISTERED LAND SURVEWOR Z07-"' Z 61, ..:.:.... . -74� (v LCACAC61 ��• 2-42 77/sTP,eoposGD tv,,7�S�ViCEsevncv S C Le�+oH Z07- 13'� BAS/N zS 9Z5 .S',p FT 1 1 t � goa f/Il/ s LOCATION Now- E7Ev.�nvNs l3�st�n o v SCALE . .�. �=.30.�. . . DATE g04y/.7/W Z;�--/ PLAN REFERENCE . B�?V. . LoT .!' . . . . . . . . . . . . . . . . . . . . . . IA OF o EDW " . 41f.M ZBiG1 h I CERTIFY THAT THE 41, SHOWN ON THIS PLAN IS LOCATED ON THE GROUND #Iu AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. DATE : . . . . . . . . . . . . REGISTERED LAND SURVEYOR SAMZ T z DiG Z S14/&G rS TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 4"CAST IRON 12"MAXIS ' OR SCHEDULE 40 12"MAX. P.V.C. PIPE 4 SCHEDULE 40 PV.C.(ONLY) PITCH I/4"PER.FT PIPE - MIN. LEACH PITCH 1/4"PER.FT PITf3/4" ST 0 0INVERT • QNG ''° EL..s.-`//.•• INVERT INVERT e . SEPTIC TANK S DIST. -� wV. ° INVERT EL..>'`a'-. 3. BOX . . >_� o /490. .. GAL. INVERT �' ►-EL.....:7... EL.sS,3G INVERT ;•' w w a: I/2.. . �0 0EL:?`f..... e. D/7'—�+-6'DIA. .o.• • �`—' /o' DIA. PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE p- .3¢77 SOIL LOG WITNESSED BY : DATE TIME. 4-1-1 BOARD OF HEALTH TEST HOLE I TEST HOLE 2 L-1�IyA92p ��. lC�Z�G�/ ENGINEER ELEV. .-'7. !;.`'. . . ELEV. .. .. . . . . . . WouDLcR-ry 3z~ s�6_so,c. DESIGN DATA c2. COg12s@ WiTfJ NUMBER OF BEDROOMS S�ivo [ayE�zs of TOTAL ESTIMATED FLOW . . '33�. . • GALLONS/DAY 84 62 FL BOTTOM LEACHING AREA 7f ��. , SQ.FT. /PITIC P D. �Z .4o.So k9e SIDE LEACHING AREA . . .i88'�. . . SO.FT./ PIT147/ C-RD D, GARBAGE DISPOSAL N'�"��`. .(50 % AREA INCREASE) D o S,c�wD TOTAL LEACHING AREA . . . . 7. . SQ.FT v PERCOLATION RATE LASS 7;%A-`o 7Z✓O, MIN/INCH Zo ��z.47,So LEACHING AREA PER PERCOLATION RATE SQ.FTI. CRZD NO .WATER ENCOUNTERED Pi i Wi NUMBER OF LEACHING PITS . J. 77/. APPROVED . . . . . . BOARD OF HEALTH U • • S/DES DATE . . . AGENT OR INSPECTOR N OF�yj ss9 =o ED �, o KE LEY M. Na 7 ,Q NIL 26100 C y G/NCa•GN. �-o•�1D. .CXT F � � �,/Y�l✓/V/Si� SS '��SUPVE+�ISTV- SoNRARIA� PETITIONER