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Home My WebLink About0039 MASSACHUSETTS AVENUE - Health a %:09 MAS"'A ':E, OYANNIS 0 uu 1 C17734 # ' �s�ri�Qk vw i f I 4 I� I a I j ��,., \, J t is �� t i i , � - 'Town of Barnstable - r 5�� - • P# Department of Regulatory Services , ,„ Public Health Division Date amass. - ;5 �1639.�� 200 Main Street,Hyannis MA 02601 + � Fp Mla + hr� Date Scheduled Time Fee Pd. ( � ; -Q . -n Soil Suitability Assessment for Se e Disposa l� Performed By: >'L C�� Witnessed By. s ` LOCATION,& GENERAL'INFORMATION ;.x., ,._ AX";. . Location Address 39 Massachusetts Ave „ . ` 'Owner'slslameJohn F: &Christine M. Gregg Hyannisport 44 Grayton Avenue _ Address Hyannisport, MA 02647 — Assessor's Map/Parcel: 287/33/ 1 ^ - Engineer's Name Sweetser Engineering Robin W.Wilcox NEW CONSTRUCTION REPAIR XX Telephone# 508-385-69,00/ Land Use ��/�v yr�"�'L Slopes(%) 6 Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft $ Drainage Way ft Property Line d'V-AgIft Other ft SKETCH: Street nam�d m�of lot exact locations of test holes& erc tests locate wetland's in proximity to holes ( P P tY ) a .. S L o �cvao� AP6A/40` M55A ij Parent material(geologic) �IJT`��L�' Depth to Bedrock w D Depth to Groundwater: Standing Water in Hole: /,�0 Weeping from Pit Face Estimated Seasonal High Groundwater ` H DETERMINATION FOR SEASONAL..HIGH WATER TABLE _ r Method Used. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level F r - PERCOLATION:TEST bate Time w., w.... ... ._ Observation Hole# 1+ F t Time at 9 e_ r , r;r .. Depth of Perc '- � ,!'. f33 t. . :., _ , i _.. . .'_.Tirrie-at`6':.'. Start Pre-soak Time @ +' Time(9"-6") End Pre-soak Rate MinAnch ,r r t�.>:r.��--. . ,l; f.• - {.li;{I7 �i .• f.t:, :,u IrT��..ry.l..' r 2 •t. { ... ii "� i r. . E Site Suitability Assessment: Site Passed i Site Failed: r Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back------------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC ` DEEP,OBSERVATION'HOLE LOG Depth from Soil Horizon Soil Texture-,. Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 3• Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# ? Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottlirg • (Structure,Stones,Boulders. ' Consistency,%Gravel p DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) `DEEP OBSERVATION HOLE LOG Hole# y. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel), Flood Insurance Rate Mal): Above 500 year flood boundary No_ Yes v y Within 500 year boundary No •'Yes y Within 100 year flood boundary No Y// `Yes Depth of Naturally Occurrin¢Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y� If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)-.I have passed the soil evaluator examination approved by the. Department of Environmen Pr on and that the above sis was performed by me consistent with the required trainin �experi'ence describ 0 CMR 1 17. Signature - C% Date ' -• '4 , • .- d ,,f ; .t .. 1. si .s,. ! ;+.i re, a .• - •f,. .. Q:\SEPTIC\PERCFORM.DOC Barnstable Town of Barnstable � Regulatory Services Department "'' 'f" MASS i639 Public Health Division Q D � OtA�A 200 Main Street, Hyannis MA 02601 200� Office: 508-862-4644 Richard V. Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3197 han February 29 2016, a L John F. & Christine M. Gregg 44 G -3-tDn Aven Hyannis Port MA 02647 0, �T L r) vj . ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave, Hyannis Port, MA was last inspected on 2/24/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: •. Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH c ean, R.S. HO . Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2015.doc Town of Barnstable Barnstablee� Regulatory Services Department 1 wka 1 ""M Public Health Division 639 '',� 200 Main Street, Hyannis MA 02601 200� Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3197 February 29 2016, John F. & Christine M. Gregg 44 Grayton Avenue Hyannis Port MA 02647 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave,Hyannis Port,MA was last inspected on 2/24/2015 by Matthew F. Gilfoy, a�certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from'the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action.. PER ORDER OF,THE BOARD OF HEALTH c ean, R.S. HO . Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2015.doc I • Town of Barnstable Barn Regulatory Services Department "' `ft- SS. ' Public Health Division I I s639. 1� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO P CERTIFIED MAIL# 7015 1520 0000 1971 7101 November 30, 2015 John F. Gregg 44 Grayton Avenue Hyannis Port MA 02647 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave,Hyannis Port,MA was last inspected on 2/24/2015 by Matthew F.Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the'septic system showed that the system"Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. . , Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH A ccan,R.S. CHO • Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evll39 Massachusssetts Ave Hy Prt Mar 2015.doc Town of Barnstable Barnstable Regulatory Services Department . A*AnmftCR • MASS • Public Health Division I 679�� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200 0001 0358 0561 April 01, 2015 John F. Gregg 44 Grayton Avenue Hyannis Port MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave, Hyannis Port, MA was last inspected on 2/24/2015 by Matthew F. Gilfoy, a certified.septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in ' ,future enforcement action. , t PER ORDER OF THE BOARD OF HEALTH ` 42 Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evll39 Massachusssetts Ave Hy Prt Mar 2015.doc ' Town of Barnstable Barnstable Regulatory Services'Department BARMAMME, • I MASS �� Public Health Division . 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0543 0 c� March 25, 2015 Richard Gallagher PO Box 514 Hyannis Port, MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave, Hyannis Port, MA was last inspected on 2/24/2015 by r, a certified septic inspector for the State of Massachusetts. �� The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. �o PER.ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health i QASEPTICU.etters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2015.doc • Barnstable Town of Barnstable e Regulatory Services Department i GSM ' Public Health Division I bs� ,'� °i 200 Main Street,Hyannis MA 02601 200� Offi ce: 508-862-4644 Second Notice Richard V. Scali,Director FAX: 508-790-6304 Thomas A4 McKean,CHO i CERTIFIED MAIL# 7012 1010 0000 2847 9039 John F. Gregg March 7, 2017 PO Box 99025 Boston, MA 02199 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave,Hyannis Port,MA was last • inspected on 2/24/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.303) due to the following: • Leaching pit is full and shows signs of previous backup. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. You may request a hearing before the Board of Health if written petition requesting same is received within 10 days. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T omas McKean, R.S. CHO Agent of the Board of Health Cc: Christine M. Gregg 422 Old Comers Road Chatham,MA 02633 Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2017doc.doc 1 Town of Barnstable Barn Regulatory Services DepartmentBA,IUW MASSM� ' Public Health Division 639. 200 Main Street,Hyannis MA 02601 200� s Office: 508-862-4644 Richard U.Scali,Director FAX: 508-790-6304 ThomasIA.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4990 4919 June 21, 2016 John F. & Christine M. Gregg �. PO Box 503 Hyannis Port MA 02647 } • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE The septic system located at 39 Massachusetts Ave,Hyannis Port, MA was last inspected on 2/24/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines* of the 1995 TITLE 5 (310 CMR 15.303) due to the following: • Leaching pit is full and shows signs of previous backup. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. You may request a hearing before the Board of Health if written petition requesting same is received within 10 days. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ./ mas McKean,R.S. CHO Agent of the Board of Health I QASEPTIC\Letters Septic Inspection Failures or Future Evll39 Massachusssetts Ave Hy Prt Mar 2015.doc I I I � r r. Town of Barnstable Barnstable Regulatory Services Department j AS& ' Public Health Division 659.& 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790 6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4490 4810 April 20,2016 John F. & Christine M. Gregg PO Box 503 Hyannis Port MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 39 Massachusetts Ave,Hyannis Port,MA was last . . inspected on 2/24/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.303) due to the following: • Leaching pit is full and shows signs of previous backup. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. You may request a hearing before the Board of Health if written petition requesting same is received within 10 days. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO RD OF HEALTH s c 'ean, S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2015.doc Town of Barnstable • '► MRNSr"LE, w prf �,bm Regulatory Services Department Public Health Division 200 Main Street;Hyannis MA 02601 Office: 508-862-4644 Richard Scab Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,'2007 - Re'v. 7/6/15 DEADLIMS TO REPAIR-FAMED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) I An"x"marked in the ❑is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last yeas not due to clogged or obstructed Pipe o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLWE CRITERIA o Static liquid level in'the distribution box above outlet invert due to an,overloaded or clogged SAS or,cesspool ❑Any portion of the SAS, cesspool, or privy, below high groundwater elevation i o Any portion of-the cesspool within'a Zone 1 to a public well ❑A:ny.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) „r XLeacbing pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) OTHER • �•Q�2.- �i�¢��o f� in+o�c i� � G��d e�I .e � o i 1 �PRepair deadline: r i Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc TOWN OF BAMSTABLE LOCATION SEWAGE # VILLAGE I��' �'o ASSESSOR'S MAP & LOT OZI �33 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: °2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i fir vY-4 s�t 1Z 4{n ��3 � Town of Barnstable Barn Regulatory Services Department "' ftCft FAASS`"� ' Public Health Division I 200 Main Street, Hyannis MA 02601 2007 r Office: 508-862-4644 Richard V.Scali,Director , FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200 0001 0358 0561 April 01, 2015 John F. Gregg 44 Grayton Avenue Hyannis Port MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave, Hyannis Port, MA ,was last inspected on 2/24/2015 by Matthew F. Gilfoy, a certified septic inspector for the State of Massachusetts. , The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit must be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF•HEALTH Thomas McKean,-R.S. CHO Agent of the'Board of Health I I Q:�SEPTICU.etters Septic Inspection Failures or Future Ev1l39 Massachusssetts Ave Hy Prt Mar 2015.doc i i I I Town of Barnstable Barnstable Regulatory Services Department Pj4nzftM9 MASS �� Public Health Division 2007 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard V:Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0543 March 25, 2015 Richard Gallagher PO Box 514 Hyannis Port, MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 39 Massachusetts Ave, Hyannis Port,, MA was last inspected on 2/24/2015 by Richard Gallagher, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR15.00) due to.the following: • Leaching pit must be replaced. ; You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTICU.etters Septic Inspection Failures or Future Evl\39 Massachusssetts Ave Hy Prt Mar 2015.doc I _ Commonwealth of Massachusetts Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Massachusetts Ave, Property Address Richard Gallagher Owner Owner's Name information is required for every Hyannisport MA 02672.: :. 2/24/15 page. City/Town State : :. Zip Code Date of Inspection Inspection results mustbe submitted on this form. Inspection forms may not be altered in any :way. Please see completeness checklist at the end of the form. Important:wnen A. General Information filling out forms on the computer, I �J use only the tab 1. Inspector: I key to move your cursor-do.not Matthew F. Gilfoy use the return: Name of Inspector ... key. .:: :. B&B Excavation . 1C=V Company:Name s. 14 Teaberry Lane Company Address Sandwich Ma. 02644 Citylrown : . State Zip:Code (508)477-0653 Sl13640 _. 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 ::: Z Fails Needs:Further Evaluation by the Local Approving Authority PP 9. Y .... p. .: 2/25/15 Inspector's • ignature.: Date The system inspector:shall submit a coPYof this inspection report to the Approving Authority (Board of:Healthor:DEP)within 30 days of completing this inspection. If.the system.is a shared system or has a design flow of.1.0,,000 god.or.greater,:the inspector and:the system owner shallsubmit the . re ort p „ 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 at time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins 3/13 ,Title 5 Official Inspection Form:S su Sewage Disposal System•Page 1 of 17 p . Commonwealth:of Massachusetts Title 5. Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..°° 39 Massachusetts Ave. s. Property Address Richard Gallagher Owner.: Owner's Names. .. information.is H annis ort . . MA 02672:: 2/24/15 required for every y P page. City/Town State :Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D.or E/always complete all of Section D A.) System Passes:. E] : 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: so ... B) System Conditionally Passes::, 0 One or.more system components as described in:the"Conditional Pass section,need to be re laced or repaired. The system upon:com letion of the re lacement or repair,,as approved b p P . ... YP P _ P _. PP . . Y 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. E] Y E] N E] ND (Explain below): p. t5ins 3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5: Official Inspe Lion Form - Subsurface Sewage Disposal System Form Not for Voluntary:Assessments .�' 39 Massachusetts Ave, Property Address . . .: . Richard Gallagher Owner:.: Owner's Name information is required for every Hyannisport MA 02672 2/24115 page. Cityrrown 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.): P 9. ❑ .Observation of sewage backu or break out or hi h 9 cted pipe(s) ,:static water level in the distribution box due i P P ( . . PP ) n box. System will t ass inspection on or s f uwlth approval rova�otlBoa d of Healthsettled or,uneven Istn utio ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): j obstruction Is removed ❑ Y ❑ N ❑ ND (Explain below) laced ❑ Y ❑ N ❑ ND Ex lam below distribution box is levee or re p : _( P ) I : I I I : L The system re uired um in more than 4 times a year due to broken or obstructed I e s The Y q. P P 9 .. . y , PP system will pass inspection if(with approval'of the Board of Health): a. ❑: broken pipe(s)are replaced ❑:Y: ❑ N .❑ ND (Explain below): I i ❑ Y ❑ .N ❑ ND (Explain below) :::::obstructionls removed s. I 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. y P . ... 1. System will pass Board of Health determines in accordance withJ310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,. safety and the environment: j j ❑ Cesspool or privy Is within 50 feet of a surface water j : ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh j t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i I Commonwealth of Massachusetts i Title 5 Official Ins ection Form p Subsurface Sewage Disposal System Form Not for Voluntary Assessments t. 39 Massachusetts Ave. ` v Property Address Richard Gallagher. Owner Owner's Name information is . required for every Hyannisport MA 02672 : 2/24/15 page. CitylTown State :Zip Code Date of Inspection B. Certification (cont.) I , 2., System.will fail unless the.Board of Health (and Public Water Supplier, if any) determines that the system is functionin in a manner that protects the public health, safety and environrh nt: g ❑ 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 all public water supply .; . ❑, The system has aseptic tank and SAS.and the SAS is within 50 feet.of a private water supply well. . : l p . ❑ The system.has a se tic tank and.SAS and the SAS is.less than 100 feet but 50 feet or more from a private watersupply well**. .. ... s. Method.used to determine distance: coliform bacteria p p p g ry g **This system asses if the water analysis performed at a DEP certified laboratory, for fecal teria 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 p. 3:: Other: i _. D) System.Failure Criteria:Applicable to All Systems: You mustindicate"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 on surface waters ® due to an overloaded or clogged SAS or cesspool ElStatic liquid level in the distribution box above outlet:invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than 1/day flow t5ms-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 .. l I Commonwealth of Massachusetts Title 5 'Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - I . 39 Massachusetts Ave. �. Property Address i Richard Gallagher Owner:.. Owner's Name information is . required for every Hyannisport MA 02672. 2/24/15 I page. CttylTown 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 El obstructed pipe(s). Number of times pumped: I . E] E] Any portion:of the SAS,cesspool or privy is below:high grou I d water elevation. El portion of cesspool or privy is within 100 feet of a surface water supply or - tributary to a surface water supply, i ® Any portion of a,cesspool or privy is within a Zone 1 of a public well. ® An portion of a cess ool or privy is within 50 feet of a private Y P P y p e water supply well. ❑ mO 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,forfecal coliform bacteria indicates absent an'd 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.] I The system is a cesspool serving a facility with a design flow of 2000gpd ❑ .:® 10,000gpd: The s stem falls. 310 CMR 15.303;wherefore the system.aboveas the fails. The system:owner should contact the Board of Health to determine what will be necessary to correct the failure. I E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either `yes" or"no" to each of the following, in addition to the questions in Section D. Yes .. No' i ❑ ❑ the system is within i400 feet of:a surface drinking water supply p. ❑ ❑ the system is within 200 feet of:a tributary to a surface drinking water supply. g i ( head Protection . ❑ ❑, the system isaoca.ed in a nitro en sensitive area ntenm e Area IWPA) or a mapped Zone 11 of a public water supply well If you have answered yes"to any question in Section E the system is considered a significant threat, . or answered"yes" in Section D above the large system has failed. The owner or operator of any large System considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 office of the Department. 15.304. The system owner should contact the appropriate regional l t5ms-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth:&Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Massachusetts;Ave. Property Address Richard Gallagher Owner. . Owner's Name information is - MA required for every Hyanni'sport - 02672 2/24/15 page. City/Town State :Zip Code Date of Inspection C. Checklist Check if the following have been done, You must indicate"yes" or"no".as to each of the following: Yes No ❑ ®: Pumping information was provided by the owner, occupant, or Board of Health _. ElWere any of:the system components pumped out in the previousawo weeks? ® Has the:system received normal flows in the previous two week period? Have large volumes of water been introduced to:the system:recently oras 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.backup? ® ❑ Was the:site inspected for signs of break outs ® ❑ 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. S:ystem Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ms 3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth & Massachusetts Title 5 Offi iasl Inspection Form v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 39 Massachusetts:Ave, Property Address Richard Gallagher Owner: Owner's Name information is required for every y p H annis ort MA 02672 - 2/24/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: . . . . Number of current,residents::. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage.system?,(.Include,laundry system inspection ❑ Yes... information.in this report.) No Laundry system inspected?. ® ,Yes ❑ No Seasonal use? .Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Detail: q. Sump pump?. Yes Z..No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of.Establishment: s. 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 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Massachusetts Ave. _. Property Address Richard Gallagher :. Owner Owner's Name ....: w. information is. required for every Hyannisport MA 02672: 2/24/15 page. City/Town pState Zip Code Date of Inspection D. System nformation (eont.) Last date of occupancy/use: Date Other(describe below). so q. General Information 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: Type:of System:.: Septic,tank, distribution box,soil absorption system Single cesspool :Overflow:cesspool :.: : Privy Ej Shared system (Yes or no) If yes, attach previous inspection records, if any). 0 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from.system owner) and.a copy of latest inspection of the I/A system by system operator under contract Tight tank.:Attach a copy of the DEP approval. . ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection , F®rrn a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�° 39 Massachusetts Ave, Property Address Richard Gallagher Owner: Owner's Name ...information is H annis ort MA 02672: 2/24/15 required for every y p page. CityfTown State Zip Code : : Date of Inspection 77 D. System nformation (cont.) Approximate age of all components,date installed (if known).and source of information: 1985_.. Were sewage.odors detected when arriving at the site'?: ❑ Yes: ® No: Building Sewer(locate on site plan): Depth:below grade- feet 1/2' feet Material of construction: cast iron :: Z:40 PVC ❑ other(explain): Distance from private water.supply well or suction line: 20' .. feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time.of inspection building sewer appeared to:be in good working order no sign of leakage. so p. Septic:Tank(locate on site.plan): Depth below;grade: feet Material of construction: ® concrete metal❑. ❑ fiberglass El polyethylene:: other.(explain):.. If tank is metal;list age years Is age confirmed by a Certificate of Compliance?.(attach a copy of certificate) ElYes ❑ No 1500 gal. Dimensions: no sludge Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts . r Title 5 Official Inspection Foem Subsurface Sewage Disposal System Form-Not for Vol u ntaryAssessments . '' 39 Massachusetts.Ave.. Property Address Richard Gallagher Owner.. Owner's Name information is required for every Hyannisport MA 02672: 2/24/.15 page. CitylTown State Zip Code Date of Inspection D. System:.Information (Pont.) Septic Tank(Pont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness r no scum Distance from top of scum to top:of outlet tee or baffle no scum ps Distance from bottom of scum to bottom of outlet tee or baffle no scum measured How were dimensions determined? . Comments(on pumping:recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels:as related.to outlet Invert, evidence of leakage, etc..): At time of Inspection septic tank:appeared ao be in working order: j. i Grease Trap,(locate:on site plan):,. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethyleneE 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 Rate of last pumping: . Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i t Commonwealth of Massachusetts , Tit e 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t r 39 Massachusetts Ave, _ 1 Property Address Richard Gallagher i Owner. Owner's Name information is. l required for every Hyannisport MA 02672: - 2/24/15 page. City/Town State :Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,:evidence of leakage,:etc.): l Tight or Holdin Tank tank must be um ed at time of ins ectlon locate on site Ian : g ( p P p ) ( P. - � - Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene Eother(explain): Dimensions: .: Capacity. gallons . Design Flow: gallons per day i 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.): j I : i i i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i i t5ms�3/13 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17: Commonwealth of Massachusetts Title 5 .Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Massachusetts Ave. Property Address Richard Gallagher Owner . Owner's Name information is required for every Hyannisport MA 02672 :.. 2/24/15 page. Citylrown 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 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 time of inspection d-box appears to in working order:no sign of:carryover.:(under deck) F. Pump Chamber(locate on site plan)` Pumps in working order: :❑ Yes ❑ No* q. 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: _. i t5ins�3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .,� 39 Massachusetts Ave, Property Address Richard Gallagher Owner :Owner's Name information is. H annis ort MA 02672 2/24/15 required for every y p page. City/Town State Zip Code Date of Inspection D. System: Inforihation (cont.) Type: IZ leaching pits number: _. .... ... ... ... _. leaching chambers: number: ❑ leaching'gallenes : 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.): At time of inspection leaching is full and shows signs of.previous backup. Leaching must be replaced. s. Cesspools (cesspool mustbe 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 Indicationof groundwater inflow ❑ Yes ❑ No t5ms-3/13 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Massachusetts Ave, Property Address Owner_: . Richard Gallagher Owner's Name information is p required for every y H annis ort -MA _.02672: 2/24/.15 . page. City/Town State Zip Code Date of Inspection M System Information (cont.) Comments (note condition:of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.): Privylocate on site Ian f P. ): Materials o :construction: Dimensions ,. . Depth of solids :. Comments(note:condition:of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.): 4. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I � Co.MOMonwealth:of`Massachusetts Tithe 5 official Inspection Form Subsurface:Sewage Disposal System Form-Not for Voluntary Assessments ' 39 Massachusetts Ave. Property Address Richard:Gailagher Owner Owner's Name. information.is annis o required for every H y p rt MA 02672 2f24/14 Ps9e• :Cityrrown 7§tate :Zip Code Dateof Ins pection' 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 10o feet. Locate where public water supply enters the building. Check one of the boxes below: { hand-sketch in the area below . drawing attached separately - 6: O ' ? El t5ins•3113 Title 5 Official Inspection Form:subsurface Sewage Disposal system•Page 15 of 17 e Commonwealth of Massachusetts r Title 5 Official Inspection-; Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ... .�' 39 Massachusetts Ave. Property Address Richard Gallagher Owner: Owner's Name information is required for every Hyannisport MA 02672 : - 2/24/15 page. City/Town State Zip Code : Date of Inspection D. System Information (cont.) i Site Exam: ® Check Slope . . Surface_water : .. Check cellar ® Shallow wells depth to high groundwater: Estimated. 12' . .. feet Please indicate all methods used:to determine the high ground water elevation: ® , Obtained from.system design plans on record 5 If checked, date.of design plan reviewed: /31/85 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 IJSGS database-:explain: You must describe how you.established the high ground:water elevation: Plan on:file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 17 Commonwealth of Massachusetts Title 5 Official lnspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �' 39 Massachusetts Ave. _. Property Address Richard Gallagher Owner.. Owner's Name information is Hands ort .MA 02672: :. 2/24/.15 required for every y p page. Cltyrrown State Zip Code : Date of Inspection E.Report Completeness Checklist ® Inspection Summary, A, B, C, D, or checked ® Inspection Summary D.:(System Failure Criteria Applicable to All Systems) completed:: .. ... .... ... .... .. .... ... System Information- Estimated depthto high groundwater..:.: Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file p. so t5ins-3/13 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION �/� D�9SS SEWAGE # VILLAGE ! ®A*r ASSESSOR'S MAP & LOT a®0' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY G VVi IA, LEACHING FACILITY: (type). (size) NO. OF BEDROOMS BUILDER OR OWNER / c/ %eb. rAa 4".f PERMIT DATE: 9 J 7- COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � �. M n ,'i - - � "�•, . • .� <. � o •�� W i ' �� < i 0 �� •�,,, { • y' ' -- _ � ,t • n fi 9q No. Fee &�91 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pphratton for 33igpogal 6pgtem Construction Permit Application for a Permit to Construct( )Repair(k)Upgrade( )Abandon( ) El Complete System V Individual Components Location Address or Lot No.3 t7 AfS S A v 11Y PO�f Owner's Name,Address and Tel.No. Map/Parcel �Y Assessor's Map/Parcel a _� tf 1 CA,-r) 62x1z � re Install is Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � eRAIC° 3S� -for 9,9f-AP00 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1)7 4�/ 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 system in operation until a Certifi- cate of Compliance has been iss d by this Board of Health. �+ Signed Date Application Approved by C Date Application Disapproved for the following reasons Permit No. Date Issued t1 �No. / Fi Fee —&V y... THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:. y ? Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETT Application for Mi!5pozaf 6petem Construction Permit Application for a Permit to Construct( )Repair(k/)Upgrade( )Abandon( ) ❑Complete System V Individual Components -Y Location Address or Lot No. !,' �f7z}S S Av oOe fI— Owner's Name,Address and Tel.No. 0041'Cl / Assessor's Map/Parcel �J >jV3� �/ O� /� lhi re Install s Name,Address,and Tel.No/ / Designer's Name,Address annd—Tel.No. /T f8 CXA/c0 3s1* WOIA- S% rv- Y/J.t o? ? 9 S-a.r o'o Type of Building: ` Dwelling No.of Bedrooms Lot Size sq.ft:%,.:. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures w Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 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 system in operation until a Certifi- cate of Compliance has been iss ed by this Board of Health. �+ y Signed Date Application Approved by Date Application Disapproved for the following reasons I Permit No. Date Issued ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by M d '.0 SG .d xx- 57' y4,e at � SS ValP17 s b en constructed in accordance with the p isions of Title 5 and th or Disposal System Construction Permit No. �' dated Installer Designer C, The iss ance of this permiirt s all not b' construed as a guarantee that the syste will functtiion as de tied. Date t- `7 Inspectorf `i �1 lo. -�! / � -- ------------------------- No. Fee `..._ (( // THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migogal *pgtem Conotructton Permit, Permission is hereby granted to Construct( )Repair(K )Upgrade( )Abandon( ) System located atd!/h'SS and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Coristructipa must a copWleted within three years of the date of tl s e t. �d a Date: Approved by O 10CATION SEWAGE PERMIT NO. VILLAGE 1 -•lo,.i 5 too V�r INSTA LLER'S NA M E A A0DRLSS Q g . o1 ? Q 1fJG a UiLDE q Dig a 11Eq pit A-55 Add 0Y lklki(s GRT1 PERWIT ISSUED 5131�P� DATE C 0 M P L I A H C E ISSL' SD J 04 RID h \f No...g......._....?- F�$............_..........._ G- THE COMMONWEALTH OF MASSACHU-SETTS BOARD Off' HEALTH .............. ...............OF........................ ...... ......... Appiiratiou for Disposal Works Tontitrnstuan Errant Application is hereby made for a Permit to Construct ( ) or Repair (>() an Individual Sewage Disposal System at: ....- 'AAA s6.1►�+5....0 )......... ------------------------------- ' ........ ............. ..� Location-Address or t.No. .�.�r( . (7'.MP.------•-----------•-------•---------- ---------------�C4ss--�e/--� ` ... S(b2T 5:..-- Add a lY............1 . �I�! wner� . L. N }�*'F"'�+�_ re � ._.'...._'.___ ..:..............................................................'. '_.."__._.._......__-.___"^.____'a -"-'7............ ....................... Installer Address d Type of Building Size Lot..............--------------Sq. feet Dwelling—No. of Bedrooms.............................._.............Expansion Attic ( ) Garbage Grinder'( ) Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other Eltures .........---•-------•---•------- - W Design Flow.............. .. ....._........_...gallons per person per day. Total daily flow..............z .......I............gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter-_-_--__•__-____ Depth..._............ x Disposal Trench—No.................... g Total leaching area... ...sq. ft. Seepage Pit No........`------------ Diameter Width Z`.9... Depth elowinlet........ - Total l leaching n a rea.ea _...3�............... ...sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date............._. �-1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ a -----•-•---•-----------•---------•-----•--------••--------•-•-•----•••...............•----•---•...... ..... ..-------------•-----_...I......................... ODescription of Soil--------------•.................---..._....---'•------...-•---•--------------••------------------------•-----------------------'----•---••••-. V .....-------•---•----'-----•'----•---•-••--'--•-------------------••-•-----•-....-•-'-••-•------•-•--•'---•----•--•-••--•-'----•••----•-•--••---............----•--•••-•----•- 1 U N ure of Repairs or Alterations—Answer when applicable_.lkSms,.......... ...v�l ._..�_��.._`.._ .....:. _ Agreement: The undersigned agrees to install the afore cribed 'ndivi(!# Sewage Disposal System in accordance with the provisions of TITI.% 5 of the State Sanitary ode—The un s ed.further agrees not to place the system in operation until a Certificate of ompliance has b issue y th o do l h. Application Approved BY = ......................•-----•------. -•--- -S I � ..... Dafe Application Disapproved for th f o to ' g reasons:........................................................................................:---••......--••••..... ..................................................................................................................................................................................--•-------••------------ Date PermitNo......................................................... Issued....................................................... Date 1 - �r No................-....... Fu$............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® . F t HEALTH � (... OF.........:............... A k�........................................... Appliration for Diipmal Works Tonotrn.rtinn Prrutil Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: l ...... 5.�V�.--..�!'�:�'.��SaJ h1�.Gk.... -------- --•--•--••-------------- ..... --•-•----•-------------••------•--------•------•------......------...... ocation-Address or t No. ........... ..... .................... Owner Addres ijC a �.... ----------------------------------------•- .......... ••,.............5.... ............................. Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms_________________ _____________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria (. ) Otherfi;�tuL�§ ............................................................................................................ w Design Flow..............._ ________________________gallons per person per day. Total daily flow..............._............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length......._.... Total leaching area....................sq. ft. 4(Seepage Pit No......... ........... Diameter......�.Z .--- Depth below inlet____._.___ ....... Total leaching area.....31-.S___sq. ft. Z Other Distribution box ( 1) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-•....................•--•----•--•-•----•-----_....---••--•---....---------......_••--.....__............................................................ 0 Description of Soil..........--------------------•-----•-•---.._........•-•--•-----•-----•--•-•-------•-----------------------•--------•----------------------------------___...•--••--••- x W U Nature of Repairs or Alterations—Answer whenpplicable__IuSTL r____ IIRCL !-S � - 1 SArAr L l)' }' -- --- --------- -- _..0°'t-••---��-� 1--- ?� ! `�� ......'4 --`-......t'` I 3 S7a�r Agreement: The undersigned agrees to install the afore cribed Individ I Sewage Disposal System in accordance with the provisions of T 5 of the State Sanitary ode— The and si d further agrees not to place the system in operation until a Certificate of Compliance has b issued y th oa d f h Ith. n ........... ...k Date � Application Approved By___....... ___ __ _ ___ ____ _______________•-•-••-- ..._._.__-_��__.�_3-� _ 5.--- Da Application Disapproved for the f o o g reasons:................................................................................................................ .......................................................-•••-•---_.___.__-••--•••••--••••--•--•--•-•••--•--•••••••-•--••-•••••••-•-•------•-•----••••••-•-----•••--•-•••-•------•-••----•---•-••••-..... Date PermitNo......................................................... Issued._........----------•-•---•-•............-•---•----•••. Date w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................�p..!....OF..................................................................................... xfiff6tr of Tamplinnrr 4' THIS IS TO CERTIFY, Thati`the Individual Sewage''Disposal System constructed ( ) or Repaired ( ) Installer ...........................................................has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for;Disposal Works Construction Permit No......................................... dated.........................._..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTE-'-TH1�`r HE SYSTEM WILL UNCITION SATISFACTORY. DATE. _.1... ......................................... Inspector........ .....ct9q.. _.___._ 1r THE COMMONWEALTH OF MASSA USETTS BOARD OF HEALTH -,r .................................................. ) .......................OF....................._....,_...._. .So d N.o........................ FEE....1 ir� �tl r Tnnatrilatt pautit Permission is hereby granted --- •- -• ..,....... •'--•-•.............••-•---•••••....----•....-•-••._.._....__...--••••..._._.. to Construct ( ) or a air (X) an Indiiviiduall Sewag INS °o�s Sys 0-4--- at No.. C............. � _--- --#-- iJil ---------------••--•-•--_---__ - "' !+ ,: .. Street •- as shown on the application,for Disposal Work Construction Permit No.2, '"_'Sligated------�-':_al__.-.95._........ ............................. I D rdHe DATE....... .•----- . ---- 1' ... ->, FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS {1y �. 1