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Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name '
information is Q��
required for C E4VID RNFST MA 6-21-17
every page. Cityrrown State Zip Code Date of Inspection I.4
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: A. General Information 3
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A.BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
.Company Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
5084204534 S14297
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 i
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-21-17
Inspectors ignature 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.
1
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Lori VS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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:
AT TIME OF INSPECTION 2 SYSTEMS MET ALL MINIMUM PASSING REQUIREMENTS. THIS
REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR
INCREASED USAGE. FRONT SYSTEM IS FOR LAUNDRY, SLOP SINK IN BASEMENT AND
GARAGE BATHROOM. BACK SYSTEM SERVES THE REST OF THE HOUSE. AT TIME OF
INSPECTION BACK SYSTEM WAS IN NEED OF PUMPING BADLY. OWNER STATED HE HAD
NEVER PUMPED IT. FRONT SYSTEM DID NOT APPEAR TO BE USED AS MUCH MOSTLY FOR
LAUNDRY.THIS REPORT IS NOT FOR BEDROOM COUNT DETERMINATION.TANK WAS
PUMPED ON 7-7-17 BY DEBARROS SEPTIC.
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 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•3/13 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 , 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6 21-17
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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:
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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 aseptic 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
El ® 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
El ® 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 '/2 day flow
t5ins•3/13 Tide 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
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6 21-17
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.
❑ ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every 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 ,
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
AT TIME OF SEPTIC INSPECTION THERE WERE 2 SYSTEMS FOUND ON THIS PROPERTY,
ONE IN THE BACK THAT CONSISTED OF A 1000 GALLON TANK,D-BOX AND 3 LEACHING
GALLEYS. AND ONE IN THE FRONT THAT CONSISTED OF A CESSPOOL AND TRENCH THAT
ACCORDING TO PREVIOUS INSP REPORT WAS OVER 50 FT LONG.
Number of current residents: 3
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ElYes ❑ 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
15—290.4 16--246.5GPD HOUSE DID HAVE A DISPOSAL THAT WAS DISCONNECTED(SEE
ATTACHED PICTURES)
Sump pump? ❑ Yes ❑ No
Last date of occupancy: currently
occupied
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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 76 BAYBERRY DR
Property Address,
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: currently occupied
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool.
❑ Privy
❑ 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):
Cesspool and trench front. Tank d-box and galleys out back.
t5ins•3/13 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
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
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:
FRONT APPEARS TO BE ORIGINAL BACK SYSTEM FROM 1989
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 line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 11 INCHES
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 GALLON
Sludge depth: HEAVY
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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
Scum thickness HEAVY
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK WAS FUNCTIONING WITH WATER FLOWING INTO D-BOX AND GALLEYS BUT WAS
BADLY IN NEED OF PUMPING AT TIME OF INSPECTION. OWNER STATED THAT HE HAD
NEVER PUMPED THE SYSTEM.TANK WAS PUMPED ON 7-7-17 BY DEBARROS SEPTIC.
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
t5ins•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
M s ' 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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.):
BACK TANK WAS PUMPED ON 7-7-17 BY DEBARROS SEPTIC.
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El 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-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
M , 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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.):
D BOX WAS FUNCTIONING AND LOOKED TYPICAL FOR ITS AGE WITH SOME SIGNS OF
CARRY OVER AND CORROSION PROBABLY DUE TO LACK OF MAINTENANCE
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:
E
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 76 BAYBERRY DR
'Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits number:
® leaching chambers number: 3
❑ 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.):
GALLERYS HAD APPROX 18 INCHES OF LIQUID AT TIME OF INSPECTION. I PROBED INTO
STONE BESIDE GALLEYS AND FOUND CLEAC STONE ABOVE THE LIQUID LEVEL. PICTURES
ATTACHED.
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
l5ins•3113 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
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Citylrown 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.):
i
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 BAYBERRY DR
Property Address
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
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
t5ins-3113 Title 5 Official fnspection 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
M , '� 76 BAYBERRY DR
Property Address
BECKWITH
Owner Owners Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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: OVER 20
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:
ATTACHED PREVIOUS PASSING INSPECTION REPORT P 11.
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 V
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Commonwealth of Massachusetts
w r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 76 BAYBERRY DR
Property Address.
BECKWITH
Owner Owner's Name
information is required for CUMMAQUID MA 6-21-17
every page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Page 9 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMA �U11�,1A�IA 02637
Owner: Btu.' i'IH,ROIIIDR"t
Unt.e of Inspection: - APRIL 2 200I
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 Locale where puhlic water supply enters the building.
y�7£,?9
Title 5 Inspection Fomi 6/15/2000 10 ~
Page 11of11 • d - � - --
OFFICIAL INSPECTION FORM—NOT
FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMAQUID,MA 02637
Owner: BREKWITH,ROBERT
Date of Inspection: APRIL 2,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater feet
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.
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
X Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
GIS DATA—OVER 20'TO WATER. _
Title 5 Inspection Form 6/15/2000 11
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-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE 0FF'ICE OF ENVIRONMENTAL.A.FFAIR.S _
DEPARTMENT Or ENVIRONMENTAL PROTEMOr
350 MAIN STREET
WEST YARMOUI'H,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 76 BAYBERRY LANE
CUMMAQUII),MA 02637
Owner's Name: ROBED BREKWITH
Owner's Address: 76 BAYBERRY LANE
CUMMAQUID,MA 02637
Date of Inspection APRIL 2,2001
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the in:fouimation
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 sc.Vage
disposal systems. lain a PEP approved system inspector pursuant to Section 15.340 of Title 5 t3lo
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector sl submit a copy of this.inspection report to the Approving Authority(Boar:]of
Healdi 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 t:ie
appropriate regional office of the DEP. The original should be sent to the system owner and copies ;;ent tot
lie buyer,if applicable,and t:he approving autliority.
Notes and Comments
REAR SYSTEM TITLE V, FRONT SYSTEM LAUNDRY
""This report only describes conditions at the time of inspection and under the conditions 01'use at
that time. This inspection does not address how the system will perform in the future under thie same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMAQUID MA 02637
Owner: BREKWTTH ROBERT
Date of Inspection: APRIL 2 2001
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 CUR
15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repa..red.
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 deter)inined"
please explain.
_ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally uns+nmd,
exhibits substantial infiltration or exftltration or tank failure is imminent. System will pass inspection if the exi!�dng
tank is replaced with 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 Complianc,:
indicating 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 al proval
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 v:itl
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
' h 4
ND explain:
Title 5 Inspection Form 6/15/2000 2
. q
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTRJJJED)
r � ,
Property Address: 76 BAYBERRY LANE
CUMMq )UID MA 2637
Owner: BRFKWITH ROBERT
Date of Inspection: APRIL 2 2001
C. Further Evaluation is Required by the Board of Health: N/A
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)tb at the
system is not functioning in a manner which will protect public health safety and the environmeu.t:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that t ite
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 :>f 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 public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply cell,
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fry ern 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 co.aform
bacteria and volatile organic compounds indicates that the well is free from pollution from that I'aciIity
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,proviJed
that no other failure criteria are triggered. A copy of the analysis must be attached to this form
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTMMD) ,
Property Address: 76 BAYBERRY LANE
CUMMAQUID MA 02637
Owner: BREKWITH ROBERT
Date of Inspection: APRIL 2 2001 `
D. System Failure Criteria applicable to all systems: N/A x
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 overloaded or clogged SAS or,
cesspool
X Liquid depth in pit 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(::).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation .
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A 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
N/A 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 coliform bacteria and volatile orgiulic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fats. h have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system,fails. The system owner should co:itact
` the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service 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) xr 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'answerd
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
-CHECKLIST
Property Address: 76 BAYBERRY LANE
CUMMA UID MA 02637
Owner: BREKWrM,ROBERT
Date of Inspection: APRIL 2 2001
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 obtained 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 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 c:f scum
X Was the facility owner(and occupants if different from owner)provided with information on tl.e
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information.'For example,a plan at the Board of Health.
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(3xb)]
Title 5 Inspection Farm 6/15/2000 5
Page 6 of 11 _ - -
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 76 BAYBERRY LANE
CUMtvIAQUID,MA 02637
Owner: BREKWITH,ROBERT
Date of Inspection: APRIL 2,2001
FLOW CONDITIONS"
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES_
Is laundry on a separate sewage system(yes or"no): YES [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CNIR 15.203):
Y>
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): Y
Water meter readings,if available:
Last date of occupancy/use:
,
OTHER(describe): .
GENERAL INFORMATION
Pumping Records
Source of information: NIA
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system -
X Cesspool with leaching field a
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 l e
obtained from system owner) '
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information;
TITLE V 1989 PERMIT#89-69
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE `
CUMMAQUID,MA 2637 -
Owner: BREKWITH R013ERT
Date of Inspection: APRII 2 2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC other(explain)
Distance from private water supply well or suction line: "
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): _X
Depth below grade: 11"
Material of construction: X concrete metal fiberglass poly::ahylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a spy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: . 3"
Distance from top of sludge to the bottom of outlet tee or baffle: 27" i
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,_liquid levels as
related to outlet invert,evidence of leakage,-etc.): ,
TANK AT WORKING LEVEL.TANK AND COVERS 11"BELOW GRADE. IN AND OUTLET BOTH
BAFFLES. .
GREASE TRAP(located on site plan) N/A
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 Icvels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMAQUIb MA 02637
Owner: BREKWITH ROBERT '
Date of Inspection: APRIL 2 2001
TIGHT or HOLDING TANK: NIA (tank must be pumped at time of inspection)(locate on site p1 in)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene.. other(e,,Plain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm
es or no
Al present(Y )
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches;etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) r
4
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.,):
D-BOX IS 12"X16",T BELOW GRADE. ONE LINE IN,ONE LINE OUT,CLEAN,NO SIGN OF
OVERLOADING IN BOX
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.):
• E
x ,
{
Title 5 Inspection Form 6/15/2000 8
9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMAQUTD MA 02637
Owner: BREKWITH ROBERT 4
Date of Inspection: APRIL 2 2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: ,
Type
leaching pits,number: .
leaching chambers,number: '
x leaching galleries,number 3
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.)
THREE GALLEY'S.GALLEY'S ARE 27"BELOW GRADE. 3"WATER STAIN LINE AT 12".NO SIGN O F
OVERLOADING OR HIGHER STAIN LINE.
CESSPOOLS: _ X (cesspool must be pumped as part of inspectionXlocate on site plan)
FRONT SYSTEM-LAUNDRY
Number and configuration: 1
Depth—top of liquid to inlet invert: 12"
Depth of solids layer: 4"
Depth of scum layer: 0"
Dimensions of cesspool: S'DEEP
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
BLOCK CESSPOOL,8'DEEP COVER 10"BELOW GRADE.TWO LINES IN,ONE WITH TEE,ONE WTI H
OUT TEE,ONE LINE OUT NO TEE. LAUNDRY AND MOP SINK IN BASEMENT GOES TO THIS,ALSO)
LINE FROM GARAGE. SYSTEM HAS ONE OUTLET LINE PIPE WITH STONE OVER 50'LONG.
PRIVY: NIA (locate on site plan)
R
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Farm 6/15/2000 9
r -
• Page 9 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 BAYBERRY LANE
CUMMAQUID,MIA 02637 _—
Owner: BRFRWi11-1 R013E1;0-
Dat.e of Inspection: A111W,2 2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including fies to at least two permanent reference landmarks or.
benchmarks. Locatc all wells within 100 feet. I..ocale where public water supply enters the building.
50
77777771
t h
\ 3��
cy --z-- — ---
--- srti
Title 5 Inspection Form 6/15/2000 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: 76 BAYBERRY LANE
CUMMAQUID,MA 02637
Owner: BREKWITH,ROBERT
Date of Inspection: APRIL 2 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater feet
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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
X Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
GIS DATA—OVER 20'TO WATER. _
Title'5 Inspection Form 6/15/2000 11
Robert Beckwith
76 Bayberry Lane, Cummaquid, MA 02637
Town of Barnstable
Public Health Division
To-whom-it may-concern:
I purchased my home at 76 Bayberry Lane approximately 25 years ago from the original owners, Robert
& Matilda Page-who reportedly had"had the house'constructed around 1961 according to'Royal Barry
Wills specificatio.ns.-The house_was.a-three.bedr_oo-m_cape.design_and_had a_new,Title-Five_septic.system-
installed just before my purchase.
We did not need three bedrooms at the time( my son was not born until 1996)and decided to convert
the bedroom at the front of the house adjacent to the front door into a family den.To do this and have
it look appropriate for a well -designed home considerable work was done;the front wall was knocked
out and a large full four-window bay with built-in seating installed,directly exposed to the front
walkway;also for easier access and a more spacious view a second doorway right next to the front entry
was installed with a ten-light sliding French door.This room has been well used as a family social and
entertainment area for the past 20+years and there has been no inclination to convert it otherwise.
A year and a half ago we decided to move my 20 year old son who was attending 4-C's out of the guest
room and into a third bedroom loft being added as a shed dormer.This addition was beautifully
constructed by Capizzi Home Improvement under permit number B 20143279,except that a town-
based requirement for a five foot wide opening in the former bedroom downstairs was overlooked.
Probably because the conversion of this room to a family room leaves no doubt as to its purpose.
Nevertheless,.the_final_sign-off of the-permit_is being-withheld until the issue is_resolved-
The reason for my writing this petition to you is to resolve this matter with a slight compromise due to
some hardship and extra expense to me;to increase the present hall opening to five feet,considerable
reconstruction-of the_hot_air_ductwork..under_the_floor(as_well as.the_intake_&._outlet wall.registers)_
would need to be included. However, if the opening could be increased to four feet, it could be
accomplished without such a large overhaul of the existing construction. I would greatly appreciate this
consideration from the health department. I am a retired and handicapped 71 year old with a
neuropathy problem and can use all the well-placed forced hot air heat I can get.
Thank you sincerely,
MIV ON6 ADbat55 PO Box �S3` /3A)Rn1SrlI3LE 026 3 0
P/JOAI; s0 g 3/
6Z 1941
TOWN OF BARNSTABI.E
LOCATION S=�T G�� SE-WAGE #
VILLAGEl',mg4al a ASSESSOR'S :MAP & LO i3
INSTALLER'S NAME PHONE NO. J0, f'aoev 777S'4211 y
SEPTIC TANK CAPACITY . /da® 61-4
LEACHING FACILITY:(t7pe) G- � 3 (size) 3
PLO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER iOa�lr
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ::i-
VARIANCE GRANTED: Yes No �/
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Board of Health
Town of Barnstable
P.O. Box 534
No.__�.:. ............. Flyahnls: Massachusetts or.-01 F�s......Za............_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Oyu,'' HEALTH
............. oWn...................OF.��rns .
Appliration for Dispati al , orko Tonitrnrtion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at:
� ------------------ --------------------------------------------------------
Location-Addr sr or Lot No.
PSG • Q4e .......................................................... ��
. n
Owner Address
w : 73 C�un z.......................... ..35.o 9414 5A!40+14!9 ... 12PIPPAA......_..__..._.....
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures --------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date------------------.....................
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water-..--..-..-.--.-------_
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water...--_.-.------.--.----
04 ---•........................•-•-------•---•-------•-----------------------------•••------.----..----------
----
•.............................................
0 Description of Soil........................................................................................................................................................................
x
U
x --------------------•...................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable-Mi.440 AqRQ.-
•Agreement:
greement:�--�-.�- o..4 ...CcV("rr .................................................................................................................
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of A! E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......d.5? .00m. .................................. ......-..?�j_. 4.--------
Date
Application Approved By................ ....--•�• ----•-•-- -I Date Application Disapproved for the following reasons:_---•-------------------------------•---------------------------------------•--•---------------•-------......••-
....................•-•----------•--•......-•--------------------------------------•------...----------...---------------------------------------•-----------------------------------------••------------
pp Date
PermitNo..... L/",19.............................. Issued.......................................................
Date
FEs............`.....-..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-•----.....1 ...........................OF...............-..........................
Appliratinn for lli ipviia1 �ark� Cann xnr iun ernti
Application is hereby made for a Permit to Construct ( ) or Repair ( >! ) an Individual Sewage Disposal
System at:
Location-Address 1 or Lot No.
Owner Address
Installer Address '
d Tye Of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Caieteria
a YP g P ( ) ( )
Other fixtures _.. ---------------------------- ---------------------
W Design Flow............................................gallons per person per day. Total daily flow._............._....._........._............gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------------.. Depth................
Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1--1 Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------------------------------------------
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•...
........
----------------
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•-----------------------------------------------------
ODescription of Soil........................................................................................................................................................................
x
U •---------------------------•---------•---•---•----•-•--------------------•----------------------•-••---------------------•------------•--•--. ........................................................
W - -------------- ------- ---------------------•-•----•------•• •••-••••••-•••-••-•-•--•-••--•••----•-•-----------•------•-•---•---••----••-•-•---••----••••------•-•----•--••-•-••-••--•----•---••--
UNature of Repairs or Alterations—Answer when applicable.-!...__�.`_�... )'! -.°. ` I
1 j !
Agreement:
The undersigned, agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTT y g g p y
5 of the State Sanitary Code—The undersigned further era agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed................................................
........................................ `j :_.....
\— Date
Application Approved By................ ......... � -�1...t -�-c- . .............I------3__e..:Af?.
Date
..Application Disapproved for the following reasons-------------------------------------------------------------...................................................
QQ Date
PermitNo.._.. l r .............................. Issued--------------------------------------------------------
Date
f� THE COMMONWEALTH OF MASSACHUSETTS
I
BOARD OF HEALTH
............'.............................OF....... ................"'........................................................
Tntifiratr of f amplianrr
THIS IS TO.CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (;L)
by19....�.... ..........................
�--� Installer Q
at ............-----�-------------•-- - ..................................................has been installed in accordance with the provisions of TITLE he State Sanitary Code as described in the
application for Disposal Works Construction Permit No._____---_�f........................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ..................... Inspector •----•--•--
t r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t..'...........................0 F.....t...................:.'::..._.........._.........................................
No......
FEE.:.
Dispas tl Worhp %Taantrn.rtion anti#
Permission is hereby granted...................A.-O--- ' ..-•----------------................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy
atNo......................... -6----- . --.tic..-------- _- ------------------------------------------•--------------------------•-------------•--
Street 9
as shown on the application for Disposal Works Construction Permit Noll-y__ _y. Dated..........................................
.............................. .........................................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS