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0071 ANGELA WAY - Health
71 Angela Way W. Barnstable P A = 133 070 4,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way Property Address ra Laurence Joseph Owner Owner's Name information is required for every West Barnstable ✓ Ma. 02668 02-15-2019 ? page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key.. 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 02-18-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts �- Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 4 bedroom home has a H-10 1500 gallon septic tank and a H-10 D-Box feeding two precast leaching pits with stone. At the time of the inspection there were no visible signs of past hydraulic failure. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ?= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form ( Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 'Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44 plus GP Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information) in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `�c u 71 Angela Way Property Address Laurence Joseph Owner Owners Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. .Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way V Property Address Laurence Joseph Owner Owner's Name information is West Barnstable Ma. 02668 02-15-2019 required For every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: standard 1500 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is West Barnstable Ma. 02668 02-15-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way V Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstaale Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time:of the inspection there were no visible evedence of leakage or visible enedence of past hydraulic failure. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ida Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 71 Angela Way V� Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c , Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r TOWN OF BARNSTABLE LOCATION V�q e, SEWAGE# �✓ S�3 VILLAGE �; l�c���S l�'�)�� ASSESSOR'S MAP 6�LOT '�� i; �'J INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY n I LEACHING FACILITY:(rype) K (`"�5 (size) NO.-OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED. DATE.COMPLIANCE ISSUED- r-S'-S 2 VARIANCE GRANTED: Yes No i i A Fe ✓ �''s �0 o LD it 0 -0 F.cvc C_ - r- _ 7 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Angela Way u� Property Address Laurence Joseph Owner Owner's Name information is West Barnstable Ma. 02668 02-15-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 16 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 71 Angela Way Property Address Laurence Joseph Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-15-2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFICE OF ENVIRONMEN'T'AL AFFAIRS 3 DEPARTMENT OF ENVIRONMENTAL P 0TREED W SEP 2 .9 2002 TOWN OF HEALTH DEPT. TITLE 5 OFFICIAL INSPECTIONFORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ��► --� 5 —7 CERTIFICATION Property Address: 71 ANGELA WAY WEST BARNSTABLE, MA 02668 133-O—W Owner's Name: ROSS Owner's Address: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Am Date of Inspection: 9/4/02 Aft ; ,, Name of Inspector: (please print),i JOHN GRACI Company Name: SEPTIC INSPECTIONStAb Mailing Address: 11 P.O. BO?C1119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT,. s 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'tiine'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.; 5'34`0 of Titlet'5(310 CMR 15.000). The system: X Passesd _ CoIty es _ Neluation by the Local Approving Authority _ Fa Inspector's Signature: Date: 9/4/02 �The system inspector shall suthis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this insystem 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. Notes and Comments ' SYSTEM PASSED TITLE V INSPECTION:RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE: ****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 syste►n4ill perform in the future under the same or different conditions of use. Page 2 of 11 :,i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t: PART A 51 t CERTIFICATION (continued) Property Address: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 i Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.,RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system compone'0t$„as-dgscribe0 in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacemen ;or,,�pair,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. n/a The septic tank is metal and over 26"year's 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. ND explain: n/a Y ` n/a Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled,4 uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced obstruction is removed distribution'bok is leveled or replaced ND explain: n/a " n/a The system required pump ethan,4,times a year due to broken or obstructed pipe(s).The system will pass Y q p P €�„y ,4. � � :� � i inspection if(with approval of the Board of Health): _bmken,.pi,pe(s)are replaced _obstruction is removed �,aVr ND explain: n/a Page 3 of I 1 . i . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 C. Further Evaluation is RequiredYby 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. P , 1. System will pass unless^Boa4of Hea1'th determines in accordance with 310 CMR 15.303(1)(b)that the system is `+? to :; I - - . , 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 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. fi _ 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'SA' S and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a rj fi G "This system passes if the well water a tznalysis y ,performed at a DEP certified laboratory,for coliform bacteria and It volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogenis 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: x r. Page 4 of l I ' ass OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANGELA,WAY WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 i= D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an over loaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NO PUMPING INFORMATION. X Any portion of the SAS,cesspool or privy is below high ground.water elevation. X Any portion of cesspoo'For privy is within 100 feet of a surface ater supply or tributary to a surface water supply. X Any portion of a cesspoo'1 o`r,privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 cola.form bacteria and volatile organic compounds indicates that the well is free from pollution from that tac'lity 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. 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`;":ow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no tc each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no T f X the system is within 400:feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located,in a nitrogen sensitive area(Interim Wellhead Protecti-,n Area—IWPA)or a mapped Zone 11 of a public water isupply well If you have answered.'tyes".to any:question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large systeit s lia 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. d d Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ANGELA WAY WEST BARNSTABLE, MA 02668 Owner: ROSS Date of Inspection: 9/4/02 Check if the following have been done.You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information;was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obiained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank rnanholes 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 ? X _ 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.So it Absorption System (SAS)on the site has been determined based on: Yes no , 1 t X _ Existing information. For example,''plan at the Board of Health. .:'i, X _ 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(3)(b)] 14 3 X t+ 5e e ' r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):"�Q_ ON Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1500gallons--How was quantity pumped determined?HICKEY CESSPOOL Reason for pumping: MAINTENANCE TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1988 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM E` j PART C SYSTEM INFORMATION(continued) Property Address: 71 ANGELA WAY WEST BARNSTABLE, MA 02668 Owner: ROSS Date of Inspection: 9/4/02 BUILDING SEWER(locate on site plan), , Depth below grade: 8" F Materials of construction:_cast iron X40:PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER SEPTIC TANK: X(locate on site plan) Depth below grade:2" Material of construction: Xconcrefe' metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age'uonfirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H.5' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 1 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): - SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AN6 THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan). Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to•bottom of outlet tee or baffle: n/a. Date of last pumping: n/ar Comments(on pumping recommendations;,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, n/a 7 Page 8 of 1 1 OFFICIAL,INSPECTIONFORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Owner: ROSS a Date of Inspection: 9/4/02 ; ,4 TIGHT or HOLDING TANK: (tank,must be pumped at time of inspection)(locate on site plan) • 1 Depth below grade: n/a Material of construction:_concrete .metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order,(yes or no): NO Date of last pumping: n/a 0 .. Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if,presentpust be(opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. D-BOX HAS SOME SOLIDS IN IT. PUMP CHAMBER: _(locate on site plan) t Pumps in working order(yes or no): NO Alarms in working order(yes or no):NG Comments(note condition of pump chaimbe ,condition of pumps and appurtenances,etc.): n/a 's `} i { i I 3 t� R 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: 71 ANGELA WAY WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) 3 If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: nla n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla n/a overflow cesspool, number: n/a n/a iz 6 innovative/alternative system 4 Type/name of technology: n/a k Comments(note condition of soil,signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PITS,APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a ' Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) ` Materials of construction: n/a 4A Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ?k a '� A 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: 71 ANGELA WAY.WEST BARNSTABLE,MA 02668 Owner: ROSS Date of Inspection: 9/4/02 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 whe4o'ublic water supply enters the building. #4 i �� Deck J 1 J . . , 4A 46 AC - p,A BTU CQ tT G ,rl `r T f f r I ,i in Page I 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANGELAWAY WEST BARNSTABLE, MA 02668 Owner: ROSS Date of Inspection: 9/4/02 SITE EXAM _Slope _Surface water ' _Check cellar Shallow wells Estimated depth to ground water 12+feet ` Please indicate(check)all methods,used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local ezcavators,-installers-(attach documentation) NO Accessed USGS databa`e-,explain: n/a a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. r t„ f y TOWN OF BARNSTABLE LOCATION� /�►Vqe�o ti SEWAGE VILLAGE l�✓ i 4��4 S �'�'� ASSESSOR'S MAP & INSTALLER'S NAME & PHONE NO. `' Pc 3,93 SEPTIC TANK CAPACITY / 5-0 D LEACHING FACILITYAtype) �' X I" i A S (size) NO.-OF BEDROOMS PRIVATE WELL OR PUBLIC WATER) yU�e BUILDER OR OWNER K evi, -Dvz;l k«' DATE PERMIT ISSUED: +" ovc(q DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ava t �Fay.. Or Ito us r. ' Ll 6 / w .. No...... _.._��',. ;1 Fxs.......................... . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........ ce>�f-..----=--.OF.....$ 2wS'Tr ... .... ° ppliratiun for Dispaoal Works Toutitrurtiun ramit Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at ZZ lyru6E&A4 ';V'4/ i1S� �\ ................__-._.._.............._.........--••----...----------------.....---•---....--- -------•-•.......-----•-...-•-----••-------•-•--------...---------•-•-------......_......_•-----•- L cation-Addre s or Lot No. ........................ .. l q .......... - - - .... .............. ---- ......_-•-•- O er �,r� Address Installer Address Type of Building Size Lot... _®1 __Sq. feet �-, Dwelling—No. of Bedrooms............_..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type'of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures - W Design Flow__________ ....T;? 7_.__gallons per person per day. Total daily flow................ ...............gallons. WSeptic Tank—Liquid capacity ___ _ _gallons Length/&P.-- Width_&12.._. Diameter________________ Depth_�__4 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_..___:_____._.._.__sq. ft. Seepage Pit No.______.Z........ Diameter............. Depth below inlet.........C_...... Total leaching area__ ®_/...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b ..._P ........... Date. ___ __ _ Aq M8i� Test Pit No. 1......._______---minutes per inch Depth of Test Pit_____ ...... Depth to ground water_______-_____________--" r=, Tent Pit No. 2..-e__Z__.minutes per inch Depth of Test Pit.... Depth to ground water..._._'______________ P4 ----------------------------------•••---•-•-----------•----------•------------------------------------------ _-�----•------- ....................... O Description of Soil... j_l„ M �-��� " c., ��.C.o�-ll,... =�Z ..r of�t�_.,�AAD_ ......_ '_ . _.o_� `'_!�®ate- e► �C":... '/�"-sv.�_o1� 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 iITL% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of CoXhance has bee issu e and of I Ith. ram_ �Q� Dat Application Approved By........... .......................---••-_......_-•-••- ,..1...�..1P ••-•-•----•• / - '6--.. Dat Application Disapproved for the following reasons-------------••--•-•--•-•--•-----••--•-•-•------•-•--•••-----•-••-------•---•--•---••--••--••-•---••-•••••-•--- -•••---•........-•---•••••••-•-•---•-....---••--•••-••-•••-••-•-•••-.._._...•-•--••-•---•--•...---••-•----•.....---••-••-•••••••••-•--•-•-•-----•---.................................................... Date Pmit No.---..................................................... Issued-....................................................... No......................... Fps.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH uJN �_q,2 A15 7-1-1 r3�_ E ..........................................OF..... , Allpfirta#ion for Disposal Works Tonotrnrfinat Famit � Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ... _......... ........................................••-•-•-••---•-••-------•-••• •-•---•••••-------••--•-...._.....--•--•••....•••-•--•-•-•••••-•-•--•-•-•-----•--...._......•_.... L) ? /��Utiop;Address or Lot No. ......................__.......... .........---•-•-••---•--......••-•---•........••.................._.........................__.... �----....-...Ovfner-•--------------•------•^-----•------•--- Address W � .. ........ .. .. Installer Address Gl 1 0/ d Type of Building 7 Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) '04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .._..__.......--•----••--•--......---•--------------•-•--------------•-•----•-•---•--------._...• .. 5 �csy ti---------------•------------ WDesign Flow.................................lam gallons per person per day. Total daily flow............................................gallo�s:. WSeptic Tank—Liquid capacity.._..._..._.gallons Length................ Width................ Diameter---------------- Depth___.-_.......... x Disposal Trench—N�.__.........•__.,_._ Width............... Total Length.................... Total leaching area------_.e. ..sq. ft. Seepage Pit No---------_----------Diameter............._...... Depth below inlet......... ..... Total leaching area... ......sq. ft. Z Other Distribution box ( ) Dosing�U/'/-' e/U,G/AJEC-10„vG f74Z ��, a Percolation Test Results Performed by..............................................---G---•••-•••---••-.._. Date........................ �. ._ Test Pit No. 1_.__�.__.__._minutes per inch Depth of Test Pit....... _.....- Depth to ground water------�............ 14 Test Pit No. 2..........Z..minutes per inch Depth of Test Pit.....�_...._.._... Depth to ground water........................ �ri �.�J�/a ,$_' �G,-G/,t/-E©'�///�v/Ll/ �S/>�/V •.. __--- _- -- . - •---� ..�. ...... .(O DescrGflora of Soil.... ---=G. a................-�.._._� .......... U ........._..........._..._..... ............. ..__.._ % r 1 /L UW ----••----••................•-- •--•-•-••••........-•----------..................• -••••••-••-----------•-•-•-------•-•----•----•----•-••...---•••--•---•-•------••............_...-- 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 TITTLE 5 of the State Sanitary ode—jh ersigned rther agrees not to place h syst in operation until a Certificate of Co ance has en ic. e e b and of ealth. Signed --------------------------------------....................... . .................. M.. Pate Application Approved .By----•-----------•-.................................... �>�'� Application Disapproved for the following reasons:-------•-••-•-•• .. •. •-----------------••------••------------------------ .....-:--------_----- ¢` Date PermitNo......................................................... Issued•----•--•-•------•-•........................ -•---••-•-•--••-•---•--•......----•- Date THE COMMONWEALTH OF MASSACHUSETTS � BOARD,.-.OF HEALTH . .....a.....OF..............I......... y. Tyrrtifiratr of ToutpliFatta THIS IS TO CERTIFY, That the Individual,Sewage Disposal System constructed ( ,y`or Repaired ( ) by........................................................................ .. . .. -----------•-------•-•-------------•--•--•-•---•-------------..............••--.............•-- installer at--------............ A 1 •- i .� � Z h f'A tyA- U - fig r�---- has been installed in ac�'ordance with th provisions of TIT 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 CONSUE® AS A GUAit/YNTE THAT THE .� SYSTEM WILL FUNCTION SATISFACTORY. DATE... ... Inspec or........,,, . •r .._... --------------............. ; •�m0� t % "tYVww1 'Of THE COMMONWEALTH OF MASSACHUSETTS _ - ,y l�cfly►� g�> BOARD OF HEALTH OF... ...' t1iJ ,.....: No..... .................................................. FEE. . .......... 'I}' - i aa1 orka. �nnstrnrivan Trani# Permission is hereby granted ' ................... ._ :.( = = ---•----------------•--•----------------.....-•----------....•••...._...------ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System -IC, -7 atNo..... --------. . ......... .. �• w-%...i aeq..•----••---•--------------•---•-------•--•---•• -•-- F...: Street as shown on the application for Disposal Works Construction Permit No.r.,&t.S-.-�,_3 Dated.......... Board of Hea �^ DATE............................................ r.......... .............. FORM, 1255 HOBBS & WARREN. INC.. PUBLISHERS - DOYLt 'ENGINEERING ASSOC IATES;`3J1-.hd. 47 MORIN AVENUE FALMOUTH, MASSACHUSETTS 02540 TELEPHONE 617-540-4411 JOHN P.DOYLE,R.L.S. JOHN P.DOYLE III STEPHEN J.DOYLE April 17 ,1987 Barnstable Town Hall 367 Main Street Hyannis,MA 02601 .. Attn. : Mr. John Kelly,Health Department Dear Mr. Kelly, This is to inform you that our office and field crew have monitored and inspected the installation of the septic system on Lot #22 Angela Way in Bodfish Fams. We find it to be proper and meeting the setbacks. Yo s truly, John P. Doyle,R.L.S. JPD/cdl y ` �/`-r'� ewe 0'111 P � V�(mil � - Alt •i�� -�/��J 24�i ` ' ' - � I � � -__ � ., , ., --1- � - I I� I � -1 -_ I I . I I I I - I I � � . I � - - I I 1 � --:, � I � 11 � - I I - I I � - I . � . I - I I - . � � I I I 1, � I I I � . �, I I � I I . I � 7_4 - �, . �,�, I 11� I I. - -I I � I . �. I I I ., I I I I I� I I � I . I I I I . I ,; -: � , . I. I I I I I I 11 I o I �. � I - I I .I ? � I I � � I � . I � I I I . -- I I " I , " . .1 � � , I � 11 I I I . � I I . � I I I I .I � I 1 4 � I � . I I .1 - I I I I � .� I � : I I . I I . : . I 1 '4�� 1 1 , I �� ,� �� -- I I I I ''. . I � � -I� �I I - I I � . I I . I.. I I � I. I I . I I � 4�� 1 11� � I I I I . I - , I I I I I � I I . I I � . 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