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HomeMy WebLinkAbout0136 SEAGATE LANE - Health 1136-Seagate.Lane,- u� Hyannis,,- P''r A - 249 136 r � a Commonwealth of Massachusetts a9 -i3� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Center ' e MA 02632 12/9/2015 page. Cityrp6wn State Zip Code Date of Inspection N N Inspection results must be submitted on this form. Inspection forms may not be altered in arT way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, 13(1 use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. tab Company Name P.O. Box 49 Company Address eta Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further aluation by the Local Approving Authority 12/9/15 Inspe is Signature Date . The tem inspect r shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � 0 A I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 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: {. ® 1 have not found any information which indicates that any ofithe failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure icriteria not evaluated are indicated below. I Comments: II i I I i 14 B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for thle following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank;(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is Centerville MA 02632� required for every 12/9/2015 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will,pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont:): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): I ❑ 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): I i . I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: I ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner,which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ii Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private.water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section'D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue . approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins-3/13 Title 5 Official'lnspeclion 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 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped in 2013- per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® . - Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) �I ❑ 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owners Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed - 12/18/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction Fine: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 10" Depth below grade: 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: 1000 gal. Sludge depth: 1 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 136 Seagate Lane Property Address Nathan St. Onge Owner Owners Name information is required for every Centerville MA 02632 12/9/2015 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 6 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 10 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The liquid level was up to the outlet pipe. No sign of leakage. Grease Trap (locate on site plan): Depth below grade: n/a 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.H 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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:): The D-box was normal Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ® No* Alarms in working order: ❑ Yes ® No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. On e Owner Owners Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Infiitrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The infiltrators were dry and clean and there was no sign of failure A camera was used to inspect Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 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 136 Seagate Lane Property Address P Y Nathan St. Onge Owner Owners Name information is required for every Centerville MA 02632 12/9/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a (Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane I Property Address Nathan St. Onge Owner Owner's Name isrequired for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or-benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a /3 3 � ay �s� 00 y a as 30� 3 ay y o C. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owners Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25'+/- 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: Topo and water contours map ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i r Commonwealth of Massachusetts W Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address Nathan St. Onge Owner Owner's Name information is required for every Centerville MA 02632 12/9/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M s 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis. MA 03054 May 5, 2010 required for y Y every 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:W filling When filling out A. General Information W forms on the computer,use 1. Inspector: O only the tab key to move your Michael McDowell cursor-do not Name of Inspector use the return key. The Building Inspector of America Company Name 2 Brookside Circle Company Address Wilbraham MA. 01095 City/Town State Zip Code 800-626-4408 156 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that ties information reported below is true, accurate and complete as of the time of the inspection. The iinsp ion was performed based on my training and experience in the proper function and rna.:ritenance'of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15, 40 off Title 5(310.CMR 15.000). The system: is •a„��, Passes ❑ Conditionally Passes ❑ Fkails ❑ Needs Further Evaluation by the Local Approving Authority ' May 5, 2010 ;? Inspector's Signature Michael McDowell MM/mjl Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board { of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Offidal Inspection Form:Subsurface Sewage /-Paige 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 Seagate Lane Property Address H_UD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis - MA 03054 May required for y y 5, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: House has been vacant for an unknown length of time. Utilities are off to house. B) System Conditionally Passes: N/A ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain'below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for Y Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): N/A ❑ 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): C) Further Evaluation is Required by the Board of Health: NIA ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5 Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 2010 required for y y 5, every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: N/A ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank`and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ N/A Liquid depth in cesspool is less than.6" below invert or available volume is less than 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''r 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street Suite 5, Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for y Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged'or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ NIA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - El ❑ NIA Any portion of a cesspool or privy is within a Zone 1 of a.public well. ❑ ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ NIA Any portion of a.cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water.quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, . provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- I0,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310-CMR 15.303, therefore the system fails.The system owner should contact the.Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. N/A 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 El ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. Mrs•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for Y every page. CityfTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ®. Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design):` 3 Number of bedrooms(actual): 3 DESIGN flow,based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center,:Greely Street Suite 5, Merrimack NH 03054 Owner Owner's Name information is H annis MA .03054 . May 5 2010 required for Y Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 . Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? N/A ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): . Detail: Total for 2008 and 2009 was 1823 gallons,divided by 730 days equals 3 gallons per day(gpd). Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons Per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water.meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments cwM 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None at board of health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May required for Y y 5, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Septic tank appears to be original with house(1979)approximately 29 years old based on its size and condition. Distribution box and SAS were replaced in 2000 as per board of health records. Were sewage odors detected when arriving'at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12 inches feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 25 feet 5 inches feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer exits rear foundation wall 15 feet 5 inches in from left rear corner. Septic Tank(locate on site plan): Depth below grade: 8 inches feet Material of construction: Z.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 8'6"Lx4'6"WX5'D, Dimensions: Approximately 1000 gallons Sludge depth: ' 2 to 3 inches t5ins•09/08 Title 5 Official Inspection Form:Sdbsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5 2010 required for Y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont) Distance from top of sludge to bottom of outlet tee or baffle Winches Scum thickness O.to 1 inch Distance from top of scum to top of outlet tee or baffle 12 inches Distance from bottom of scum to bottom of outlet tee or baffle 16 inches How were dimensions determined? With a tape measure & pole Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Fluid level was correct, that is, equal with outlet invert. Observed concrete deterioration above fluid level and on outlet baffle. Pumping is recommended every three years. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center Greel Street Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May required for y y 5, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must,be pumped at time of inspection)(locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA ' 03054 May required for —Y y 5, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Fluid level was correct, that is, equal with outlet invert. There is visible concrete deterioration. Side walls are bowed inwards. Cover is cracked. A piece of slate was over cover. There was no evidence of solids carryover. Note: Electrical conduit to shed runs almost directly over distribution box. Top of distribution box is 18 inches below grade. Recommend anticipating replacement of distribution box. Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street Suite 5, Merrimack, NH 03054 Owner Owners Name information is Hyannis MA 03054 May required for Y Y 5, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers/infiltrators number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system ' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS consists of four infiltrators (10'x30'x2') installed in 2000 as per board of health records. There is no evidence of hydraulic failure. Note:The septic system has not been receiving normal daily flows for an unknown length of time. Cesspools (cesspool must be pumped.as part of inspection)(locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 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 M 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for Y Y every page. City/Town State Zip Code . Date of Inspection D: System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level'of ponding, condition of vegetation, etc.): Privy locate on site plan): N/A Materials of construction: Dimensions Depth of solids' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.),- Ir. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for _ Y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building:Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Sketch is not to scale Inlet cover on septic tank XA=25'6" . YA=24'3" B=Outlet cover on septic tank XB=30'8" YB=22'0" C=Distribution box XC=40'3" - YC=23'4" D=Vent - XD=69'3" YD=37'8" 02 4 f - . _ 8u3edln y Sewe —TowN 13(o Cam. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M a 136 Seagate Lane Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street Suite 5, Merrimack NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5, 2010 required for y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.). Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high groundwater: 10 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: Previous Title 5 Septic System Inspection Report stated ground water at 18 feet. Basement was dry at time of inspection and does not have a sump pump pit. Before filing this Inspection Report, please see Report Completeness.Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GSM , 136 Seagate Lane - Property Address HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Hyannis MA 03054 May 5 2010 required for Y Y every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Previous Title 5 Septic System Inspection Report dated 10-22-03, swing ties to distribution box are incorrect. Called the board of health on 4/28/10 and spoke with Lindsey. She told me that there was a previous title 5 for this property that was a pass back in 2003 and they had a permit on file for a repair that was done in 2000. They didn't have any pumping records on file. They do ask that you are registered with the town and there is a$25.00 review fee. t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION /�l� � 5� �� SEWAGE #Z0749— �5 VILLAGE ASSESSOR'S MAP & LOT 2 L/ INSTALLER'S NAME&PHONE NO. �"✓''/` a i SEPTIC TANK CAPACITY 00 � t LEACHING FACIL=: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: p COMPLIANCE DATE: 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 . o stp q6 w Z 14 J- c� No. � �i� Fee 3 06 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. d C Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migogar *pztem Con5truction Permit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) El Complete System Mindividual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.SNo. Designer's Name,Address and Tel.No. 7 a � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(1_9%� Other Type of Building S &lee 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 114pe®!a�� .�iY/S)`%�'�9 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 issued Vigo of ealth. Signed Date Application Approved by Date /L Z6We— Application Disapproved for the following reasons Permit No. 20V0 Date Issued Z ��� TOWN OF BARNSTABLE LOCATION �Cd 7� 1 SEWAGE .. Z&Va—7 -J� VILLAGE 4 ASSESSOR'S MAP & LOT 2 / INSTALLER'S NAME&PHONE NO. l ✓✓`/` f� SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) - / td�a./t�s (size) Ira 6_C NO.OF BEDROOMS BUILDER OR OWNERI � •� i�� tr1-u�LL 1 1 PERMIT DATE: COMPLIANCE.DATE: i Separation Distance Between the: j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet j 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 ` bti- o trJ IS, As 0J-- r V ' N 1✓S'� ,I M No Fee 1 u THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIppifcation for Oi5poe;al *pgtem Cow5truction 3permft Application for a Permit to Construct( )Repair( t/)Upgrade( )Abandon( ) El Complete System L�Individual Components Location Address or Lot No. 26 SLo,�i.� /� Owner's Name,Address and Tel No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. //�f Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building, ZS 1 ,eX,1•CP No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ila gallons per day. Calculated daily flow 'S >10 gallons. Plan Date Number of sheets Revision Date Title r Size of Septic Tank /0 1�9a �S/"/e?�� Type of S.A.S. d 13,�Z Description of Soil y "Op 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 issued bey his oaX4 of ,ealth. Signed Date Application Approved by Date /L Application Disapproved for the following reasons Permit No. Date Issued - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER�, that t}te 0 -site Sewage Disposal System Constructed( )Repaired( ✓)Upgraded( ) Abandoned( )by L� "� . at j 36 �5eew1_' A- 1aAef 5 has bw constructe in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NO.Z;0 4"� Z dated 1 Installer Designer The issu n epf thi ermit shall not be construed as a guarantee that the system will function as des? ned. Date ��/ �4 7 Inspector � �\� ——————————————————————————————— �/---- — No.+Z&V 7 z -1 `� /C� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLES MASSACHUSETTS = Mizpooar *potent �tConotruction Permit Permission is hereby granted to Construct( )Repair(V5/Upgrade( )Abandon( ) System located ate l I 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:Construction must be completed within three years of the date of this Date: / / � � Approved byc f i NOTICE: This Form Is To BeVsed For the Repair Of Failed Se "tic Systems. Only. _ CERTIFICATION OF SKETCH AND.,APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERNIIT(WITHOUT DESIGNED PLANS) herebythat the application certify / apphcanon for disposal works construction permit signed by me dated 17 l.b`�� concerning the property located..at ,��j cJt'q/ .�� � meets all of the following criteria: V The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. Y i ae soil is classified as CLASS I and the^e^- . .potation rate is ;ess'than or equal :o f nimutes per inc2 There are no wetlands within 100 feet of the propose d septic system /:here are no private wells within 1:0 feet of the proposed septic s+setn. =ae:a is.no increase in flow and/ change / or caan,_in;Lse propose b� There are no variance requested or needed. 2 The bottom of the proposed leachingfacility will not be located,less than five feet above she maeimum adjusted groundwater table elevation. [Adjust the groundwater.table.using the timptor method when applicable] if-the S.A.S. will be located with.250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located Iess than fourteen(14)feet above the maaamum adjusted groundwater table elevation, Please.complete the following: 5 A) Top of Ground Surface EIevation(using GIS information) I k , B)`G.W.Elevation Z-bi + the MAX High G.W.Adjustment DIFFERENCE BETWEEN A and B Zgp SIGNED A_ DATE: (Sketch Proposed plan of on hack]. (F heft&kkr,oen .A.+u (jJil ! 1 s J r �1 s � f S I { COMMONWEALTH OF MASSACHUSETTS l 12 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P7RECEIVED . EC ' o eCT 2 7 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A z4 I. .;.,. . . CERTIFICATION MAP 3 PARCEL Property Address: 1 � ; S P a gr t T•an a LOT Hyannis Owner's Name: Tr-iyzia Iyindetaer- Owner's Address: Date of Inspection: 1 0—2 2—0-3 Name of Inspector:(please print) Wi 1 1 jam _ Rob' nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (501i) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sect}on 15.340 of Title 5(310 CbiR 15.000). The system: P 'asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature.. /-V Date: ,l� �. 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies.scnt to the buyer,if applicable,and the approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 inspection Form 6/15/2000 page 1 Y Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 1 3 6 Seagate Lane Hyannis Owner: Tricia Lindauer Date of Inspection: 1 0—2 2—0 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.t/Syysstem 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: B. S stem Conditionally Passes: ne 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. Answer yes no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The se tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhi its substantial infiltration or exfiitration or tank failure is imminent_System will pass inspection if the existing tank i replaced with a complying septic tank as approved by the Board of Health. •A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that a tank is less than 20 years old is available. ND explain: Observa ion of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe( )or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Bo d of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syst required pumping more than 4 times a year due to broken or obsi x1cd pipe(s).The system will pass inspection i (with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 136 Seagate Lane Hyannis Owner: Tricia Lindauer Date of Inspection: . 1 0—2 2—0 3 C. Further Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health,safety or the environment. 1. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the Sys( m is not functioning in a manner which will protect public health,safety and the environment: esspool or privy is within 50 feet of a surface water _ C sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System w II fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fund ioning in a manner that protects the public health,safety and environment: _ The s stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface w er supply or tributary to a surface water supply. _ The stem has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The ystem has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Th system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a private ater supply well- Method used to determine distance "This sy em passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria an volatile organic compounds indicates that the well is free from pollution from that facility and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite is are triggered.A copy of the analysis must be attached to this form. 3. Other: - j 3 9 Page 4 of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 136 Seagate Lane Hyannis Owner: Trieia Lindauer Date of Inspection: 1 0-22-03 D. System Failure Criteria applicable to all systems: You ust indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or.available volume is less than'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00feet 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 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 f^_et from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,' performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. arge Systems: To b considered a large system the system must serve a faci!ity with a design flow of 10,000 gpd to 15,000 gPd• You ust indicate either"yes"or"no"to each of the following: (77te f llowing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply t e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped one II of a public water supply well If you have answered"yes"to any question in Sectim E the system is considered a significant threat,or answered "yes"in Se ion D above the large system has fnikd.The uAmer or operator of arty large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The s -stem owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 136 SeaaatP Lane Hyannis Owner: mr; n; a Lindauer Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No . Pum in information was provided b the owner,occupant,_ — P g ant or Board of Health P y , ✓ 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?• l/ — Was the site inspected for signs of break out? Were all system m components, s excluding the SAS located on site'?' — — y P g . -zl— 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: Yes ..no — 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 CUR 15.302(3)(b)) 5 r Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 '16 SPagn p T•nne Hyannis Owner: Tri a T.i ndanar Date of Inspection: 1U-22 p 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): -T DESIGN flow based on 310 CMR A 5.203(for example: 110 gpd x#of bedrooms): 0 Number of current residents: Does residence have a garbage ' der(yes or no): U Is laundry on a separate sewage system(yes or no):�of yes separate inspection required] Laundry system inspected(yes or no):, C) Seasonal use:(yes or no): 0 Water meter readings, if available(last 2 years usage(gpd)): 2 n 2 Sump pump(yes or no): k C) eS 2 0 0 3 8�5, 750 gals , 250 gals Last date of occupancy:� d CommE CU1L/iNDUSTRIAL Type of es lishment: Design flow(based on 310 CMR 15.203): gpd Basis of des gn flow(seats/persons/sgft,etc.): Grease trap resent(yes or no): Industrial w ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met readings,if available: Last date occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Wo U Was system pumped as part of the inspection(yes or no): 4 0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP 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) _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 or no):LL 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 1 3 6 Seagate Lane Hyannis Owner: Tricia Lindauer Date of Inspection: 1 o-24Lo3 BUILDING SEWER(lo to on site plan) Depth below grade: Materials of constructio _cast iron 40 PVC_other(explain): Distance Gom private ter supply well or suction line: Comments(on condit' n of jousts,venting,evidence of leakage,etc.): SEPTIC TANK:_ locate on site plan) ) )D Depth below grade: ��oncrcte Material of construction: _metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is confirmed-by age g y a Certificate of Compliance(yes or no):—(attach a copy of certificate) v J Dimensions: Sludge depth:_ !A Distance Gom top of sluge to bottom of outlet tee or baffle: X Scum thickness: y _ td r ► Distance from lop of scum to top of outlet tee or baffle: O Distance Gom bottom of scum to bottom of outlet tee or baffle: ► How were dimensions determined:___a�l�i p.i �® ') $g Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of le age,etc): D v Q "" 7 ,f !-� '0 GRE, E TRAP:_(locate on site plan) Depth bel w grade:— Material o construction:_concrete metal_fiberglass_polyethylene other (explain): Dimcnsio s: Scum thi ess. Distance om top of scum to top of outlet lee or baffle: Distance Gom bottom of scum to bottom of outlet tee or baffle: Date of ass pumping: Comm nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rela ed to out invert,evidence of leakage,etc.): 7 e Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Seagate Lane Hyannis Owner: Tri ri a T,i ndauer Date of Inspection: in 2 2_n 3 TIGHT or HOLDIN TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructio : concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes o no Alarm level: Alarm in working order(yes or no): Date of last pump' Comments(condit' n of alarm and float switches,etc,): DISTRIBUTION BOX: (if resent must be o ened locate on site plan)P P )( P ) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): / O l� PUA1P CFlA111BE (locate on site plan) Pumps in working rder(yes or no): Alarms in workin order(yes or no): Continents(note ondition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Seagate Lane Hyannis Owner: mri ri a Lindauer Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type 1 aching pits,number:_ aching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): S �,� �, l� II ) �d Lr Lv .� Jy o ►�,, Y6 J'� � CESSP OLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number a d configuration: Depth—to of liquid to inlet invert: Depth of s lids layer. Depth of sc m layer: Dimensions of cesspool: ' Materials of construction: Indication o groundwater inflow(yes or no): Comments( ote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVYts(note, (locate on site plan) Materiaonstruction: Dimens Depth os: Comme condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Seagate T.ane Hyannis Owner: Tricia Lindauer Date of Inspection: 1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. U 31 q0 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 Seaaate Lane Hyannis Owner.- Trot,; a Lindauer Date of Inspection: 1 O—2 2—o SITE EXAM w Slope Surface water , Check cellar Shallow wells Estimated depth to ground water Z feet xry Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) r 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.hi h gr:unA water elevation:222 11 .. No...... y, ...... Fps...... 5...— THE COMMONWEALTH OF MASSACHUSETTS X .. BOAR® OF HEALTH .................. ........................O F...-..-..-...........--......-......-...--------------------.-...-.........-•-•--•-.-•...- �-3 ApplirFa#ion for Disposal Works Tonstrnr#ian ramit VZ Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System t: .............. :.. : e....o.. � ��,►5----------------.. ...-•---------•----:-----.............--1 '-----------------..........-----..._.._......---- cati"n-A dyes or Lo .._....:. �1L1X?r1 .. �lt� ------------------------------------ ------- ��.. ��►' ..� .... :. U ................... 4 Owner Address 1.4 Installer Address Type of Buil ing Size Lot... 1, ... ._.._._._Sq. feet . U Dwelling—No. of Bedrooms.3_____________________________________Expansion Attic ( ) Garbage Grinder ( ) `k Other—T e of Building _______________ No. of persons-__...-.__-____._____-_..._. Showers — Cafeteria 0.' Other fixtures - - ------------- W Design Flow_______________ .......gallons per-hers per day. Total dail flow_.____-__2. __�-.._____._--_...._..__gallons. W Septic Tank—Liquid"capacity__��__gallons Length...�_.�.... Width......7---- Diameter---------------- Depth................ x Disposal Trench—No. __!_______________ Width.................... Total Length.................... Total leaching ft. 3 Seepage Pit No----------/........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosingtank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ aTest Pit No. l.....-3......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........................ --------•-------------------------------•--•-----------..--•-----------.................----•----------------------••---------------_-----•-•-•-------------- Description of Soil x •-.'�� /a l....----='1�-��-----��--------^-r-�-----�T.....:.......................................... v W x ----•--------------- ----------------•-•-•-----•-•--•----------••----•----•-----••---•-------•--•-•-----•-------------------------•-----------------••-----•----....__.._.....----------------...--•--- 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 IT the � 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 b the hoard of health. ,,�/ Signed --- 4 `� .......................... Date Application Approved BY =- �L ----_----1 a = y-"7 . Date Application Disapproved for thei011-0wing reasons-----------------------------------•----=------------•----------•----•--•----•----•---•----••----------•••---- --•------•---------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------_...•- Date Permit No------- 9.................:. Issued. � 7. . Date NO.--... :�1. ...... F�$.... . THE COMMONWEALTH OF MASSACHUSETTS e BOARD OF HEALTH .................. .....------......OF...........................:.......... Appliration for Disposal Works Tonstrurtinn rmutit ��.i Agp) c,�tion is hereby made for a Permit to Construct or Repair ( ) an Individual S^`ewage sposal system-it, ........... ...: .. ..._:. ................. ........................... ... .. - ............... .. Laati......... OQlZ ...-••-••-••-•.......................... .....o �V LOU ................... Address .. ...Installer Address c Type of Buil ing Size Lot...lf 0 -------Sq. feet �-, Dwelling—No. of Bedrooms. .. --_--Expansion Attic ( ) Garbage Grinder ( ) a r a Other.—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----------------.._ _...•--• ......•----• . W Design Flow..... ... gallons Pasw�'per day. Total dail flow...........2 3..r-�........... .....•_--gallons. WSeptic Tank—Liquid capacity !'.gallons Length....-, :-*, .... Width...... -_-- Diameter................Depth................ x Disposal Trench No -e .... Width.................... Total Length.................... Total leaching area..,&.'Je..sq. ft. 3 Seepage Pit'No...._..__�--_-__-- Diameter.................... Depth'.below inlet.................... Total leaching area..................sq'. ft. Z Other Distribution box ( A) Dosin`g tank' ( ) ~' Percolation Test Results Performed by..................................•--•--------•-----•-•••--•------•-•--•.. Date........................................ a Test Pit No. l-------3......minutes per inch Depth of Test Pit.................... Depth to ground water........................ f=, Test Pit No 2 ... minutes per inch Depth of Test Pit.................... Depth togrotnd water........................ ^� O Description of Soll - � '�' " fi - - . ii; %,,�- p ,x a. .......---•-•-------...................................................... U Nature of Repairs or Alterations—Answer when applicable......:.. ... ................................................................................ ............................................... •••---•..........•---•--•-•--•-----.........:_................----•---••--••----------•--••--•=-=....................................................... Agreement: _" - The undersigned ia'ees to, install the aforedescribed Individual Sewage,Disposal System in accordance with the provisions of:T11L 5°of the State,Sm atarya Code "-The undersigned further agrees not to place the system in operation until a Certificate ofTCompliance has�been i fithe9b aid f ta lth ` {' } Signed ...: ......... .......................... Date Application Approved By...... G -7 Date Application Disapproved for the 911owing reasons::............ .....................................................-Y.............................................................................-----------------------------------------.......................... Date _ Permit No....... .................................... Issued Issued_...... -----• ..........� Date 7 1 TtCO'MMONWEALTH'OF MASSACHUSETTS fF ,` j e firma BOARD OF HEALTH � . r �4A ....... ........OF....... ....................................................... x .�410 wA 14i � t� s THI�IST,0, CE TIFY, That the Individual Sewage Disposal System constructed O or Repairedby..----- -$----- -------------- ••---••...�er�i�irtt#r of �unt�li�anrr'94� ------ •••---••-•-•••-•-•-••---•---.....--•--•......--.....-•-•..... .._....•-----._.....-- -- Installer . f ---- -..........-•---��-------•--------- -----•--.._....----- -------..._.......-------- 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"Pertlui-ND ,.. .... . '�S`................... dated. .._-14.^__ .�'_7_ ._._._...._._. F' THE ISSUANCE OF-TI41S CERTIFICATE SHAL `AOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION 'SATISFACTORY u DATE.. :. .....------- ............. ........... Insp - tor-------......--------- = ................................. THE COMMONWEALTHOF MASSACHUSETTS BOARD OF HEALTH '* T , !iW bt No......... FEE ••�•. . ........... N1\ y_ . ��..,..�....... nrkvtll�t�irtilan rrnti� Permission is hereby granted.. ... to Construct ( ) or Repair ( )�,an Indivi�YualtSewage Disposal System at No._.. o .E' I . f `f ✓ 6c�R f ....•---- . ---- •-•-•- ........ ._..._ .� �• . ... as shown on-the..application for Disposal `�Torks Constf ct>onr P ;' it N-. _xS'"____ Dated_...- .'.��� ,7 .-_•. - Board of Ieal DAT.E.:, ; cif ......................... ,lx FORM 1258'H8138S & WARREN. INC.. PUBLISHERS 1,56 LO &,T10 E WO,64E PERMIT UO. VILLAGE C�' !I\1 TALLER 5 U ME ADDRESS 'A� t ,� BUILDER 5 Q A/tE 4.DDRESS DATE PERMIT ISSUED ` ' ATE COMPLI &t�ICE ISSUED • - 1 .�, , „� ..t .. , _ / !1 E � r V i -.._. _ 6 moo o t�CJ��Q/ fiprJ _ /moo Sz C8. GG r y _ - - - e x%'I 9�o vn d pr-ofile- S C 7-1 O /�./ -o- o -o---o- ProPoSGo� grouno� �rofi/G. HO/E'/2. SCALE : / _ /O L/6- ,eT. 5.G.44- E- SCHeO. 40 ,C v C. OAE!! m/r7irrnur77 14 Pew foot , / EQc/AL 7-0D SEPT/G m 2" of �a - /L�„ wnSfisal afore! B..L1 ELE✓. 6 _z v pi5T BOX T h8Gl4, r�A PibDodCd 6 SumF7 0 0 •'4: v All /DDO 64e- $E•PT/G Ti-7/V� ! , . - - c�ashad Stor,c M 3 74 I � ` ,,0\p �� ''IPA ,/� ��• t� l_ � r Qtf TIq / G�AGH PST ki 41 tA T `yi /"':'JE-"�' /t./� ,✓ _ •� 1 �� P , ,, , �_ 8 6 L?.�O'CJ/i!J H`Gi v S c- G'f=,� T �:• ' F ... Ef �- - / S f,,��+�� A,!,/A/GH Dy ter/ � � f 4' q 7 �� 6�9 L S Ofii Y 7 7 /�.5 G�j Ste= f'T/C. T�9A-/. • fhb / ;, c��� 1000 Go•ro oq G A, , 7-. /� WarEiF. C->/A/ /G-` _ � _ GACa EFF. L?E•®TN ����-- ,met/ _r/? 5 _ /G �L 46dA/ C ' ' 9 5 /` �.�• 0 1 s _1 � ,4 GsAL S � r r .3 ASOT TOM 4•' a S F 33 _ ' L yGAY �.' TOT'9L. c�SE . (_EACH P/7- �orrP I • s'A e/-7 t?n e e r-i r'9 c /L. es,..ac/,vt 46,ess Fo Ae L O T /? JvL /V A J EEO-^� /94 e-AA/G S v,!Vim''r-O r2 SS - - AF 776-, ro i9 -s-- >'f�• 'MOUTH , M/q S S• Y G /�7 / �as `t` •' ''� a S /9 I- iR S S�-1 O�./N O/9 T E L J[,// r ` dl�l�,��`�j+=�: i EMS.. Ya�M�•r �l a��' S / T 1- /49 ti Y,S "�- �7 - - - G X / Sfir, Co/-7foc�r�r ©f HC—AC._T/-/ ' q -o-o-o-o - ProRO ,D,/ ct�rr -ot✓rS t`�-f�,EJ,LJSTi :`=: _ c- , MASS 78- G7 93