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PARCEL LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME A ADDRESS B U I L D E R OR OWN ER 1-�elle DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED d � ___._—; ��s� r �- �_ �5 ', �� 1 ---; � f . . , No...........J`....... Fizz.......�0..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............TlWW..P........OF............. .............................. AVVftrativu for Bhipasal Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: PINE ........................ .. .............................. ........................ 1,calit.11dr s Lot'Nai ......... ................ .................Le-kiA 9"VA---R.If.................................... Ad 61 1..flss ....................... .......................................... .................... t-C---------------------------------------- Installer Address UType of Building Size Lot----- !�_�P.Sq. feet .a,3 _�._7 Dwelling—No. of Bedrooms Attic (AQ Garbage Grinder (tJC) Other j------A Cafeteria —Type of Building .....!�!�----t!4...... No. of persons......________________CX----­-­------ Showers (OL) 04 Other fixtures ........................................................................................................ ...................................... Design Flow.._.... .........................gallons per person per day. Total daily flow.......... 0---------------------gallons. WSeptic Tank—Liquid ts.14PrOgallons Length----14�...... Width-----4....... Diameter.__-_4dr... Depth................x Disposal Trench—No. ....._®._._ ____ Width.................... Total Length......___.........._ Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter....._...___.__..... Depth below inlet................_... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) t 9 - ;��......... Date..... Percolation Test Results Performed by--- ......... Test Pit No. I...... ........minutes per inch Depth of Test Pit_6�4� pth to ground'wa/e!;V ............ 4, Test Pit No. 2................minutes per inch Depth of Test Pit_._............_.... Depth to ground water..____........_......... P4 ............ ............. ............. ....... ...... ........ ................ 0 Description of Soil..... 0- ....✓V__V_'K'--------4'-" 1. .................... ........I........ al W - ;I....45'&ab U .......................................................................................................................................................................................... ------------ W .................... ............................................. .......................................................................................................................... �1 U Nature of Repairs or Alterations—Answer when applicable.___............................................................................................ ..........................................................I............................................................................................................................................. Agreement: The undersigned agrees to install the afore&scribed Individual Sewage Disposal System in accordance with the provisions of TIT 2 5 of the State Sanitary Code—The undersigned further aUees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt Signed... .....BAA.....C S�-). o Dat? ApplicationApproved By._..__,.,,,,_. ................................... ....................... 71 Application Disapproved for the following reasons:....................................................................................... .......................................................................................................................................................................... Permit No.................................................. Issued------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................Fc W_1)........OF...........: - 4 Applutttion"fear lliipniittl Works Tnnitxnrtion ramit w Application is hereby made for'a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy teen at: -PI -PIN, ................_•---- ........ 1J - 1-! -----...-------•- ........................---_... -------•--- .................................................. ---- Locatio Addr s or t C F k O er Ad r ss a ...---•"-`-.--�----- .1.` .C> .......................................... ...----•-•--------- _ _ _ :I::4.. ..r---------------- .._.:..___-------••--- Installer Address Type of Building Size Lot___. ..Sq. feet Dwelling—No. of Bedrooms _______ _______________________________Expansion Attic ( Garbage Grinder QU(� Other.—_ Type of Building � ..' No. of persons p., yp g p X Showers Cafeteria (jb) al Other fixtures _..-•--•••--•-•-•-----•--..... - .................................................•..._----- ------- ---•-• ' DesignFlow_-__ ___ gallons per person per day. Total daily flow...._..___ Q 40 w g P P Y Y gallons.. 0; Septic Tank—Liquid ca aci&V��gallons Length___. V_..___. Width_._.14_...____ Diameter__._-> ___. Depth_ .____._.. Disposal Trench—No. a-WO.. _-.. Width.................... Total Length.................... Total leaching area....:---------------sq. ft. Seepage Pit No_______________ ___ Diameter._._..__._._.__. Depth below inlet___._......._...__ Total leaching area............,_ s ft � ---- P -• g . _ q. . . z Other Distribution box O Dosin tan k ( ) '-' Percolation Test'Results Performed by. .A X.7. "' . Date..... __�� __ Test Pit No. 1' __ ____minutes per inch Depth of Test Prt_ epth to ground w ter_.__ 44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R: •---- ...Description of Soil-- 4 moo' ------ '�--- ............... ---...T P. -------------;; � --- 1 _ N. w UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T U 5 of the State Sanitary•Code—The under"signed further a ees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt . Signed__.! y. !1 -----W- _ 62. qst ------••-- - 7"!....... / Dae _ Application Approved By....... �- -.---"/ ................................... ' _ - -- Date Application Disapproved for the following reasons:........................................................................_........................................ -----------------------------•----------...--•----------•----.....---•---------------........-------•--------------•--•-••-•--•---------•------•--••----•---------•------•-----•---•••-•---•---------=-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH raw..k ...............OF....... ., -: 5 :1 'S. .......................... �rrtifirtt#� ,af f�unt�rlittnre T IS IS TO CERTIFY, That the I} ividual Sewage Disposal System constructed ( ) or Repaired ( ) -------------------•-----------...-------....._.._._.............---------..__....-•--..__....-----••-- Installer at.......... --•-------- 1 iV r "-----------------------------------------•---- has been installed in accordance with the provisions of TIT -5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ........ dated"_______________________________________________ THE ISSUA E F THIS CERTIFICATE SHALL NOT BE AS A GUARANTEE THAT THE SYSTEM WILLU TION SATISFACTORY. DATE-----•-`- r .............. -----........_... Inspector.:CONSTR .. .... ....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p ............. ................OF.......P�IA.;M_$"i"'ABJ�........................... r FEE.... .......... Dispos 1 lVarkii Tnnotrnrtinn ramit, Permission is hereby granted---•- - i '.��'........4-....... t. _.(_.t .......................................... to Cons rr ct ( ) or Repair ( ) an �ndividual Sewage Disposal System at No - + -- } Q1- •E-••---.._.s.7.................................................................................................... Street as shown on tyaplicadon for Disposal Works Construction Permit No_____________________ ated_. .__ . _•---..-.--- ---------=------------------------------------ DATE_ •-•---_ oard of Health FORM 1255 HRREN• INC., PUBLISHERS SIN6t•� FAMILY - � BlsoRooM — .• wo , GAcL5A.6E 100.0 DAILY FLOW s 110 X SEPT%a.,TAQK = a3oxl5o% =A956.Po USE- 1000 GAL. • i o15po_4AL PI"r- USE 1 o o0 GAL. •}I S t D4�n1AlL AcZG1► ' 1 to S.Fi ' S.F, X 2.5 F 37 G.PE� . ..... .gOTTO/4� I�.QEA l .. �� �F•- . . � 5o s.F x ►• o A �0 �,•po r b -To'TA1_ pE51GN • ,4.25 G.PD. 3 'TOTAL 'PA I LY Ft-DW - 330 I'ti°N • I PE2GO4.ATION RATE s I"IN 2MIN o9_1_655 _ _ _ IOZ I _. iZ - U OF A OF ,y L_ •` /+t``r� ate t�L* 'ls,�y ! I03•�Q Z O 1O'�'`1 . � F"CHARD ALAN -�j A. - � W '^ I BAXTER 0J NES p 9 Na 24048 . 251 � � , T FT `f 8S-I �'L. 103 Top Np•1c�i.O 4/124Is3 _10-3 L'1,• 101- . •Lot•+7 , loou . SVBfdL� B�K Ioo •(0 SCGTIC. ro0. � I Zrjy IOoo INS _T'ANK G&L. Itaa o , V LP Tu INV. INV. ' 4/I'fl1 lop.-L Ioo.d. 1 VL 4 SP•��,• vJASUG� `• C<=2TIFIGD PLOT PL.AW PRZ PILE I.oCAz_IorJ ��A►.1�1s 41p (Z Wo SCALE Sr-ALa qa S h ' ' If o: �61TUrL. P0S� N PI-AN R1=�E�ENGE k GER?tFY -TNaT TNT t-tov 51ao w F{[,•RE+OI•l GOMPL`(5 �IITF•I'CNir �1 o�L11-I 4✓ L�•- I AuD S6'TQ�GK R.6Qv12EMEN'f> o 'tNE- -rr.>w.N AND I.S I;� Pt�a �LA l��y LOCp.TE0 •WIT1A1 Y �� �' `-o D PLD. N ATWtz) 4h I $3 DAl"T gAycTEcLa IJ`(E INC.— 11 �:.. . R.E6 I S't fcQ6D'I.A1.1 D 5 u 2v EYoeS , V '1'ul Pte ►.1 I �� Nort' gnS�o ob A� oS-f"E•2 VILLC- - �• s .. _ � 129 PINE STREET, HYANNIS A=248-066 I a e I I i 1, 14L _ (] ( MGp- .2ys j I t&".r - b66 - 001 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis,, WA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f TI,rLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 129 Pine Street JAN 17 z001 Hyannis,MA Helen Kelleher TOWN OF BARNS FABLE Owner's Name: HEALTH DEPT. Owner's Address: c/o Doris Walsh 113 Oak Hill Road,Hyannis,MA 02601 Date of Inspection: January 12, 2001 Q Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number; South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT I certify that 1 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 cite 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 Needs Further Evaluation b} the Local Approving Authority Fails Inspector's Signature: S Date: i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition Of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 129 Pine Street Property Address: Hyannis,MA Helen Kelleher Owner: January 12, 2001 Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V/1 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or m 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: A,119 .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. Answer yes. no or not determined(Y,N,ND)in the 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 indicatine that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 P� Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 129 Pine Street Hyannis,MA Owner: Helen Kelleher Date of Inspection: January 12, 2001 C. Further Evaluation is Required by the Board of Health: IVIA 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 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 supple or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is %N ithin 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 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 forma 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 129 Pine Street Property Address: Hyannis,MA Helen Kelleher Owner: January 12, 2001 Date of Inspection: 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 '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. AL,0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. &L Any portion of a cesspool or privy is within a Zone 1 of a public well. A,,!a Any portion of a cesspool or privy is within 50 feet of a private water supply well. .g 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 eater 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 forma c,(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. Large Systems: h To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no'to each of the following: (The following 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 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 If 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 129 Pine Street Hyannis,MA Owner: Helen Kelleher Date of Inspection: January 12, 2001 Check if the following have been done. You must indicate`yes"or"no"as to each of the followine: 7No P..;,.-.ping information was provided by the owner. occupant, or Board of I lealth 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: 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 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 129 Pine Street Hyannis, MA Owner: Helen Kelleher Date of inspection: January 12, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3—�• �,t Number of current residents: 0 Does residence have a garbage grinder(yes or no): /vo Is laundn on a separate sewage system (yes o: nol:wo_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): ,vo Water meter readings, if available(last 2 years usage(gpd)): ?y -oo 3 3�Qo ITN t/,ti r y�y/y 9 : �y ova y //,, Sump pump(yes or no): n/o Last date of occupancy: i/;3 /o.1 COMM ERCIALANDUSTRIAL N/, Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A/o O✓....,: .� iw �6 c�✓i. /wl l— c t l3cr.+�/t. bit rY•«�•.., /'�A^r Was system pumped as part of the inspection(yes or 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components. date installed(if known)and source of information: i,c+e.II, A c /iy / e3 sit.. As- 6✓-. i+ Were sewage odors detected when arriving at the site(yes or no): 6 r Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Pine Street Hyannis,MA Owner: Helen Kelleher Date of Inspection: January 12,2001 BUILDING SEWER(locate on site plan) Depth below grade: /8"+ Materials of construction:_cast iron /40 PVC_✓other(explain): %:y a ; �i T Di�mnc:• fron, rivate water supply well or suction line: j1A Comments(on condition of joints,venting, evidence of leakage, etc.): s c I SEPTIC TANK: (locate on site plan). Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: s 'xq X i000 flog. Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: 2'6 " Scum thickness: AroNc Distance from top of scum to top of outlet tee or baffle: iyo S -�. Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Pro 6< . _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): / /- PL' 'TLC- . �. �.,.+_ w_ ...A ca..c.rc /-• sc_ -f-O � uv-}�--"-�s-r< 7ta,i_..�—�_ wQr-�_'�� U'A" No t J:e(< � /L. tG c, e e c" :l 4 'n 0 e awl u S � A �.ti IC ✓ct f h u '� l� N c e,✓l J.I` fa.i...�s �.f, a f /1 GREASE TRAP:NL(locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Pine Street Hyannis,MA Owner: Helen Kelleher Date of Inspection: January 12, 2001 TIGHT or HOLDING TANK:N/4 (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 Floe. gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) 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.): -J2-1,v rJ a S zi v r 2 /c v o- c-"-A J d: ft 11 / N D G✓ N4 N t PUMP CHAMBER:N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Pine Street Hyannis,MA. Owner: Helen Kelleher Date of Inspection: January 12, 2001 SOIL ABSORPTION SYSTEM (SAS):_y/ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: I - G X C L t leaching chambers,number: 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.): L w t, P. {a —J w fl, `/b U,�' W e 1- a a- L': . I�Ib lU/L /0 • 1 � �G j �}- IGV4/. /t/� GV.pl K h L � �Y !!�✓'YJ.V I• � I✓✓t. )) t L VV� �,.o !,/[M S iL, �L JG�1 / (N 1G.Y` �✓H� O.-`j."' �< J/'�'l+ V.� hf�pt a.fl:..._ CESSPOOLS: ,u/i (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 ofscum layer: Dimensions of cesspool Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: Ni(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 129 Pine Street Property Address: Hyannis,MA Helen Kelleher Owner: January 12, 2001 Date of Inspection: 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. r - � I I 32' 10 uPage 11 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 129 Pine Street Hyannis,MA Owner: Helen Kelleher Date of Inspection: January.12, 2001 SITE EXAM ✓ Slope Surface water Check cellar ✓ Shallow wells Estimated depth to groundwater 90'-A feet Please indicate(check)all methods used to determine the hi;h ground �%ater 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) -,/_Accessed USGS database-explain: us G.s m .As Y/ou,must describe how you established the high ground water elevation: (G) / ham/ r C o I + 7, t C- d ._+L, o{ /2 .a U S e, s le /34 11 Sewage Permit No. Location: Village: s Installer's Name & Address 14M g!, 19a/r , Builder's Name & AddressI ch el d1 ti -Py Date Permit Issued 3— Date Compliance Issued /e f \ 6