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0940 WEST MAIN STREET - Health
940 West Main Street Centerville A=249 - 055 r 1 No. 42101/3 ORA I ° ESSELTE 10% O O O O 4� t Tj 0 co A m m own of Barnstable Barnstable Regulatory Services Department e1C8C 1 * 11 i 3 DA 3LE, • MASS. � Public Health Division I I 7 MASS.�e 9. �� lf0MA�A" 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 1937 February 18, 2014 Housing Assistance Corp 460 West Main Street Centerville, MA 02640 RE: Operation and Maintenance Contract for the Innovative Septic System installed at 940 West Main Street in the Town of Barnstable. According to our records, the operation and maintenance contract your innovative/alternative wastewater treatment system at 940 West Main Street Centerville, may have expired or was cancelled. To date they have not received evidence that you have entered into a new Operation and Maintenance contract. There is also no record of any quarterly testing of the wastewater effluent from your system. Therefore we are writing to instruct you that the Massachusetts Department of Environment Protection (MA DEP) and the Town of Barnstable require that you test the effluent four (4) times each year for five (5) years. You are also required to keep an Operation and Maintenance (O&M) contract in effect at all times for your system. Information about these requirements may be found at http://www.barnstablecountyhealth.org/ia-systems/ia-owners-guide. The Barnstable County Department of Health and Environment oversees I/A septic system management and compliance efforts for the Board of Health in your Town (Osterville). The Public Health Division is hereby contacting you to inform you of the above requirement and to order you to comply. Q:\SEPTIC\O&M Itr\940 West Main St Cent Feb 2014.doc Accordingly please forward a copy of a signed contract via mail, fax or e- mail within thirty (30) days of receipt of this letter. Please be advised at if you do not respond within thirty (30) days of your receipt f this le er by forwarding a copy of an assigned contract, you will be sche uled t appear before the Board of Health at a show cause hearing on Nove be 2, 2013 to provide information relative to the required contract. PER OR ER F THE BOARD OF HEALTH Tho as McKean, R. CHO Age t of the Board o ealth Q:\SEPTIC\0&M Itr\940 West Main St Cent Feb 2014.doc outbind:H 1-OOOOOOOOD29B6432901 CDB49B3 0FFF776DBODF8507008249EAC50E 1 D794ABA69DC2D 1 D 147BDC0000... Flynn, Judith From: McKean, Thomas Sent: Thursday, February 13, 2014 8:38 AM To: Flynn, Judith Subject: FW: 940 West Main Street in Centerville Judith Please fill-out an I/A form for Brian at the County in regards to 940 West Main Street. See below for instructions. -----Original Message----- From: Brian Baumgaertel [mailto:bbaumgaertel@barnstablecounty.org] Sent: Thursday, February 13, 2014 8:36 AM To: McKean, Thomas Subject: RE: 940 West Main Street in Centerville Hi Tom, You can either fill out the attached or go to http://www.barnstablecountyhealth.org/cape-and-islands-health- agent-coalition/references-and-resources/new-ia-system-permit-summary-sheet and use the password "healthstealth". The summary sheet is the only way I can find out that a system exists, so if I don't get one for a system, I can't track it for you and we end up with a situation like this where we have a system that goes for the first 2-3 years without any testing or anything being done. Please help me help you. Thank you, Brian From: McKean, Thomas [mailto:Thomas.McKean @town.barnstable.ma.us] Sent: Wednesday, February 12, 2014 9:14 AM To: Brian Baumgaertel Subject: RE: 940 West Main Street in Centerville Please send me form that you are requesting someone else to fill-out. We have a record of a proposed I/A system at this location. However, it was not tested as required nor any O&M contract on file. Therefore, we recently ordered the owner to have it tested and to submit a O&M Contract. -----Original Message----- From: Brian Baumgaertel [ma i Ito:bbaumgaertelabarnstablecounty.org] Sent: Wednesday, February 12, 2014 9:06 AM To: McKean, Thomas Cc: Kate Ferreira (KFerreira@haconcapecod.org); Gael Kelleher (GKelleher(ftaconcapecod.orq) Subject: 940 West Main Street in Centerville 2/18/2014 outbind:H1-0000000OD29B6432901 CDB49B30FFF776DBODF8507008249EAC50E 1D794ABA69DC2D I D 147BDC0000... Hi Tom, I received an email from the Housing Assistance Corporation regarding an I/A system at 940 West Main Street in Centerville.They were in search of the reports for this system. However, I don't have a system in my database with that address. Can you check on this property to see if I should have it? If so, please send me the summary sheet for it. Also, please let me know if it's a Groundwater Discharge permit. Thanks! Brian Brian Baumgaertel Environmental Project Assistant Department of Health and Environment Barnstable County, Massachusetts PO Box 427 Barnstable, MA 02630 Email: bbaum aertel barnstablecount .or � @ Y I; Web: www.barnstablecountyhealth.org Tel: 508-375-6888 Fax: 508-362-2603 2/18/2014 p;l COASTAL AUTHORIZATION FOR ENGINEERING TECHNICAL COMPANY, INC. SERVICES 260 Cranberry Highway,Orleans,MA 02653 508.255.6511 ■ Fax 508.255.6700 r coastalengineeringcompanycom To: Housing Development Department (late:02/18/14 Project No. P140218.10 Housing Assistance Corporation Attn: Kate Ferreira Project: Bioclere Wastewater Treatment Systems 460 West Main Street Operation &Maintenance Hyannis, MA 02601-3698 T: 508-778-7535 x2 F: 508-771-5673 Location: 940 West Main St.,Centerville, MA E: kferreiraqphaconcapecod.org Assessor's Map 249, Parcel 055 COASTAL ENGINEERING will perform the following Fixed Fee: See Attachment 2 services relating to the referenced project. Contract Duration: Ongoing i SCOPE OF SERVICES: i Coastal Engineering Co., Inc.(CEC)will perform the services outlined in Attachment 1 regarding the Operation and Maintenance of the Bioclere Wastewater Treatment System at 940 West Main Street, Centerville, MA. i i t TJP/vsw D:IPROPOSALSIIHOLD42014ftusingAssistanceCorp ATS-2014-02-18.doc SUBJECT TO STANDARD CONDITIONS FOR AUTHORIZED FOR COASTAL ENGINEERING: ENGAGEMENT El We are proceeding with service(s)noted as per your By: ` V d J direction. Immediate notification in writing is required Todd J.Palmatier, Program Coordinator if you;wish to alter this authorization. ® Please execute this agreement authorizing us to Date: February 18,2014 proceed at the above fixed fee. No services will be performed until you return this agreement with AUTHORIZED FOR CLIENT: authorization in writing. This document will become our original agreement. B Title: Acceptance of this agreement by signature authorizes COASTAL ENGINEERING to proceed as described.This Date: IbL )11 proposal expires in 90 days if not signed by bath parties. PLEASE SIGN AND RETURN ONE COPY i Nousiug Assistance Corporation February 18,2014 ATTACHMENT 1 OPERATION AND MAINTENANCE SCOPE OF SERVICES The following is a summary of the scope of services to be provided by Coastal Engineering Co., Inc., Technical Services Division (TSD),for the benefit of the Bioclere Treatment Systems owner: The two treatment systems shall be operated by a Certified Wastewater Plant Operator in accordance with the requirements of 257CMR2.00 and the Board of Certification of Operators of Wastewater Treatment Plants.The treatment systems shall also be operated in accordance with the conditions imposed by the Massachusetts Department of Environmental Protection,for the permitted use and with the local Board of Health. EQUIPMENT MAINTENANCE A. Within design capacity and capability of the equipment,maintain the Biocleres for the benefit of Client. B. Document all maintenance for the Biocleres. Maintenance reports will be provided on an annual basis or by request. C. Document all repairs to the equipment. D. Perform other services that are incidental to the services specified here including facilitating emergency repairs in the most expeditious and cost effective manner at an additional cost as requested by Client. E. Pump maintenance to be performed in accordance with manufacturer's specifications by subcontractor and invoiced by them directly to the client. F. Check septic tank solids content annually.Septic covers must be at grade to allow access for Inspection and sampling. BIOCLERE MAINTENANCE 1. Standard maintenance as follows: 1. Check general condition/appearance of unit. 2. Check vent flow,odor. 3. Check general condition of fan box including internal and external wiring,lock,latch,gaskets,etc. 4. Check quiet fan operation. 5. Check condition of cover locks,latches,gaskets. i 6. Check and characterize biomass. 7. Check recycle pump operation,timing and effluent clarity. 8. Check dosing pumps operation, timing,effluent clarity and spray pattern. g. Check general condition of dosing assembly.Clean nozzles if required. 10. Check general condition of control box including locks,gaskets, etc. 11. Check control box switches,alarms,timers,etc. 12. Complete and maintain service report file. 2. Maintenance frequency as follows:quarterly Operation and Maintenance visits to perform standard Bioclere maintenance for each of the two separate systems. 3. Sampling:collect effluent grab samples quarterly from each system and have analyzed at a state certified laboratory for:pH, C-BOD5r TSS,TKN, NOx, NO3,and alkalinity. 4. Reporting: Prepare quarterly summary reports and file with the Department of Environmental Protection, Barnstable County Department of Health and Environment and the Barnstable Board of Health. NOTES: 1. Coastal Engineering will perform no procedures requiring confined space entry. 2. Services under this contract specifically do not include or cover any responsibility for system malfunction attributed to process design,equipment specified and/or installations as provided by others. 3. Client must provide access to all Bioclere System components at time of quarterly O&M visit. 4. This service contract assumes permanent occupancy of the dwelling or facility.The Owner shall notify TSD if occupancy becomes seasonal. 5. TSD will notify the appropriate authority of electrical or mechanical failure resulting In the failure of the treatment system,or of events which may adversely affect the performance of the treatment system. 6. In the event that the system alarm is activated resulting in system failure,the Owner shall notify TSD who shall notify the DEP and Board of Health within 24 hours.Corrective action shall be taken Immediately. s_ T Housing Assistance Corporation February 18,2014 ATTACHMENT 2 COST OF SERVICES 1. The yearly fixed fee costs for the services outlined In Attachment 1 shall be as follows: Operation and Maintenance $800.00 Sampling: laboratory fees included $1,200.00 Reporting $400.00 Total $2,400.00 yearly Billed @$600.00 quarterly 2. Barnstable County Database Management Fee* $50.00 3. Services performed in addition to those noted, including responding to alarms,will be invoiced at$100.00 per hour. 4. The cost for replacement equipment, supplies and process control chemicals will be invoiced at our cost plus surcharge in accordance with our Standard Conditions for Engagement(copy attached). j5. Additional sampling and testing, if required,will be invoiced at time and expense, in accordance with our ' standard rates. In the event that state or local regulatory bodies change sampling requirements and/or Operation and Maintenance requirements,the cost estimate will be revised to reflect these changes. 1 Barnstable County assesses an annual database management fee of$50.00 for each wastewater treatment management system in Barnstable County. Each July the County sends an assessment notice to Coastal Engineering Company, Inc.,for the systems operated by Coastal. Coastal Engineering pays the fee for the system owner and includes a$50.00 charge for this fee on your next invoice as a reimbursable expense. 2 j h �j No. �/' 1 y v�J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Vsposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. y',-�4© j4lad-j�VnAiN -SYL,eZ4, Owner's Name,Address,and Tel.No. Q Assessor's Map/Parcel 4 `��� PAL Os5--0 � . 4.656 , AI,,— CO hoe n Q Installer's Name,Address,and Tel.-No. ,5-b q--3&3 62Y7 Designer's Name,Address,and Tel.No. oType of Building: �cJ eti a�✓ -2�/`c y�A rV�— J�q1'� f'e�^�7r�4 o"S ?rd'-75 �' Dwelling No.of Bedrooms ( Lot Size sq.ft. Garbage Grinder 4 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title� Size of Se tic Tank ��/ �- 2. Type of S.A.S. !� 6 C-I 4AL -, M c� p . Q Description of Soil I Nature of Repairs or Alterations(Answer when applicable) i �' !A 1�oy, A e�,im/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of — - Compliance has been issued by this Board of e th. � ly eyr Signed Date 1 ^ Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No. C Date Issued 3"` —/ L/ No. . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' f PUBLIC HEALTH DIVISION -TOWN,OF BARNSTABLE, MASSACHUSETTS Yes Replication for Misposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components -7 Location Address or Lot No. ,df0 Gl/P/J! Yrl AiN Owner's Natne,Address and Tel.No. `f�'� Ai 1�411p _ f/O4/,Siy Dc-(/440Phi,..t- 1aa0f, k ,amv!S Assessor's Map/Parcel a i 1 fl 4- �55 ''Q� /�vs i(�6 FJ55/S 1 ti4-- 6o/i-4 , Installer's Name,Address,and Tel.No. S"o 8-3 b?"&2 37 Designer's Name,Address,and.Tel.No. Type of Building: l� p-e�t 6a��✓ l w c/-/A rid— /,'A_t%-- re VrejsA >`og "9-73rlr Dwelling No.of Bedrooms ( f' Lot Size sq.ft. Garbage Grinder( ) r2 wR Other Type.of Building No.of Persons Showers( ) Cafeteria( ) Other FixturesA A 1 J Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date 'Q � Title A c fi 6 L AAA. h Q Size of Septic Tank 2 Type of S.A.S. Ct Description of Soil Nature of Repairs or Alterations(Answer when applicable) _ Al s/ :54N/ rA w e-t toW k A,,P l A L&-, 13/w► C— e-A eJ v„f-- Date last inspected: 1 .. "Agreement: The undersigned,agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the syste in,operation until a Certificate of Compliance has been issued by this Board of e th. ILL r' Signed J`- Date •��f � t ^ \\ Application Approved by Date 3 (/ Application Disapproved by y, Date r.-o"fWthe following reasons Perini O I L� V Date Issued t ! L I ---------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CER FY,that the On-site Sewage Disposal system Constructed( ) Repaired( UpgradedSal ( ) 'r Abandoned )by �! at , /9/�L) has been constructed in acooydance ^/ with the provisions of Title 5 and the for Disposal System Construction Permit No. 26/Y- OP dated / Installer G— ' `�� ' i Designer f #bedrooms Approved design. ow `-,,,. /� r gpd The issuance'of this perrni a 1 c fistrued as a guarantee that the systemlldfun 'io ,as designed - = ; Date ��� Inspector l/ 4 . . - _ . -------------- ------- ------------ --_ - -- -` ---------------- 61 No. ; Fee 160 THE COMMONWEALTH OF MASSACHUSETTS. PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -gA10 ''Misposal 6pstem Construction J)Prmit _ o # Permission is hereby granted t /Construct( ) UUU pair( ) . rade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty/fro"comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be c mpleted within three years of the date of this permit:e . , Date r/ I Approved by ' �J OL lti.e �s Lx .\l - � � a q--e ery- Le�e- i I i i Town of Barnstable Barn Regulatory Services Department > Public Health Division 0 �� ° 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Intrim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 26-- April 16, 2014 Housing Assistance Corporation 460 West Main Street Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 940 West Main Street, Centerville, MA, was last inspected on 3/05/2014 by, John Schnaible, a certified septic inspector for the State of Massachusetts The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action.. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Ltr. not sent repaired 3/5/2014 Inspection report received 4/10/14 Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\940 W.Main Cent 2014.doc QASEPTIC\Letters Septic Inspection Failures or Future Eval\940 W.Main Cent 2014.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name required for every information is Barnstable MA. 02601 March 5, 2014 require 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your I J cursor-do not John Schnaible use the return Name of Inspector key. Coastal Engineering Company Q Company Name 260 Cranberry Highway Company Address Orleans Ma. 02653 City/Town State Zip Code 508-255-6511 SI 260 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:. ❑ Passes Conditionally Passes ❑ Fails ��eeds Furth rEv�aI ati he Loc Approving Authority \\\Inspector's Sign a 7Date The system in ector shall submit a copy of this inspection report to the Ipproving 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. qf Iv t5ins-3/13 Title 5 Official Ins ctio orm:Subsurface Sewage Disposal System-Page 1 of 17 j Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ride Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System_ (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town 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): Septic Tank inlet tee is missing. Recommend adding conforming sanitary tee to the inlet pipe. Recommend replacing broken cleanout cap near septic tank outlet. ❑ 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): 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5 2014 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-3/13 Title 5 Official Inspection Forth: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 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ride Job#C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 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): 10 Number of bedrooms (actual): 10 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1100 15ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 5-2 bedroom units Number of current residents: 8 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): - Detail: 2012- 950.7 gallons per day 2013-1041.1 gallons per day Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterlin Ridge Job# C18089 00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped Nov. 2013 according to HAC 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): 15ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterlin Ride Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Installed 04/27/07 according to Board of Health records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 5-7 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage. Recoomend replacing cleanout cap near septic tank outlet. Septic Tank (locate on site plan): Depth below grade: 3 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: 13' by?' by 5' liquid depth _ Sludge depth: 12 inches t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I - , Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 inches Scum thickness 0 inches Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 16 inches 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.): Recommend adding sanitary tee to inlet pipe. No pumping recommended. Tank appears to be in good condition 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 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ride Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis Ma. 02601 Owner Owner's Name information is Barnstable MA. 02601 March 5 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert All 3 d-boxes=0 inches 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.): All d-boxes appear to be in good condition. D box#2 has some solids in the sump. No repairs recommended. D boxes 2 and 3 are 2 feet below grade. DBox#1 access cover is at grade. D boxes are 6 feet below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 1-89 feet long ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ® innovative/alternative system Type/name of technology: Bioclere Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure or evidence of ponding. Liquid level in the chambers is 16 inches. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge_ Job#C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5 2014 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System (#2) Units 5-9 Sterling Ridge Job# C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �a 3° All; �-' SLP.s�v �11 J`'� \ \ � c e1` - V to CIOvo a ,3 r do t — 3 I D O� t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System_(#2) Units_5-9 Sterling Ridge Job#C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma. 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 22 from the bottom of the chamber 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: 06/20/06 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: Based on soil testing design plan and groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 West Main Street (Centerville) Back System #2) Units 5-9 Sterlin Ride Job#C18089.00 Property Address Housing Assistance Corporation 460 West Main Street Hyannis, Ma 02601 Owner Owner's Name information is required for every Barnstable MA. 02601 March 5, 2014 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 6¢� 0 NovP- I r 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COASTAL AUTHORIZATION FOR ENGINEE]UNG TECHNICAL COMPANY, INC. SERVICES 260 CGanbeiry Kiighway,Cbleans.MA 02653 508.255.6511 w Fax 508.255.6700 % coasblengineeringcompany.com To: Housing Development Department Date:02/18/14 Project No. P140218.10 Housing Assistance Corporation Attn: Kate Ferreira Project: Bioclere Wastewater T realm eni Systems 460 West Main Street Operation 8 Maintenance Hyannis,MA 02601-3698 T: 508-778-7535 x2 F: 508-771-5673 Localion: 940 West Main St-, Centerville, MA E: kferreira haconca ecod.or Assessor's Map 249, Parcel 055 COASTAL ENGINEERING will perform the following Fixed Fee: See Attachment 2 services relating to the referenced project. Contract Duration: Ongoing SCOPE OF SERVICES: Coastal Engineering Co., Inc..(CEC)will perform the services outlined in Attachment 1 regarding the Operation and i Maintenance of the Bioclere Wastewater Treatment System at 940 West Main Street, Centerville, MA. i I TJ P/vsw D.V>POPOSAL SII HOLD%20141HousingAssistanceCorp-ATS-2014-02-18,doc SUBJECT TO STANDARD CONDITIONS FOR AUTHORIZED FOR COASTAL ENGINEERING: ENGAGEMENT We are proceeding with service(s)noted as per your By: TO ' direction. Immediate notification in writing is required Todd J. Palmatier, Program Coordinator d you wish to alter this authorization. ® Please execute this agreement authorizing us to Dale: February 18, 2014 proceed at the above fixed fee. No services will be performed until you return this agreement with AUTHORIZED FOR CLIENT: authorization in writing. ®.This document will become our original agreement. B Title: "v QOPL' 121]l (YJ 0,2 Acceptance of this agreement by signature authorizes i COAS-TAL ENGINEERING to proceed as described.This Dale: I����►�{ proposal expires in 90 days if not signed by both parties. PLEASE SIGN AND RETURN ONE COPY Housing Assisurnee Corporudon February 18, 2011 ATTACHMENT 1 OPERATION AND MAINTENANCE SCOPE OF SERVICES The following is a summary of the scope of services to be provided by Coastal Engineering Co., Inc., Technical Services Division (TSD),for the benefit of the Bioclere Treatment Systems owner: The two treatment systems shall be operated by a Certified Wastewater Plant Operator in accordance with the requirements of 257CMR2.00 and the Board of Certification of Operators of Wastewater Treatment Plants.The treatment systems shall also be operated in accordance with the conditions imposed by the Massachusetts Department of Environmental Protection, for the permitted use and with the local Board of Health. EQUIPMENT MAINTENANCE A. Within design capacity and capability of the equipment,maintain the Biocleres for the benefit of Client B. Document all maintenance for the Biocleres. Maintenance reports will be provided on an annual basis or by request. C. Document all repairs to the equipment. D. Perform other services that are incidental to the services specified here Including facilitating emergency repairs in the most expedllious and cost effective manner at an additional cost as requested by Client. E. Pump maintenance to be performed In accordance with manufacturer's specifications by subcontractor and invoiced by them directly to the client. F. Check septic tank solids content annually.Septic covers must be at grade to allow access for inspection and sampling. i BIOCLERE MAINTENANCE I Y: Standard Tnafntenance-as-follovrs: - - 1. Check general condition/appearance of unit. 2. Check vent flow, odor. 3. Check general condition of fan box including Internal and external wiring,lock,latch,gaskets,etc_ 4. Check quiet fan operation. 5. Check condition of cover locks, latches,gaskets. i 6. Check and characterize biomass. 7. Check recycle pump operation, timing and effluent clarity. 8. Check dosing pumps operation, timing, effluent clarity and spray pattern. 9. Check general condition of dosing assembly. Clean nozzles if required. 10. Check general condition of control box Including locks,gaskets, etc. 11. Check control box switches, alarms, timers,etc. 12. Complete and maintain service report file. 2. Maintenance frequency as follows:quarterly Operation and Maintenance visits to perform standard Bioclere maintenance for each of the two separate systems. 3. Sampling:collect effluent grab samples quarterly from each system and have analyzed at a state certified laboratory for:pH,C-BOD5,TSS,TKN,NO2, NO3,and alkalinity. 4. Reporting: Prepare quarterly summary reports and file with the Department of Environmental Protection, Barnstable County Department of Health and Environment and the Barnstable Board of Health. NOTES: 1. Coastal Engineering will perform no procedures requiring confined space entry. 2. Services under this contract specifically do not include or cover any responsibility for system malfunction attributed to process design,equipment specified and/or installations as provided by others. 3. Client must provide access to all Bloclere System components at time of quarterly O&M visit 4. This service contract assumes permanent occupancy of the dwelling or facility.The Owner shall notify TSD if occupancy becomes seasonal. 5. TSD will notify the appropriate authority of electrical or mechanical failure resulting In the failure of the treatment system,or of events which may adversely affect the performance of the treatment system. 6. In the event that the system alarm is activated resulting In system failure,the Owner shall notify TSD who shall notify the DEP and Board of Health within 24 hours.Corrective action shall be taken Immediately. I • Housing Assisranre Corporarion February 18, 2014 ATTACHMENT COST OF SERVICES 1. The yearly fixed fee costs for the services outlined in Attachment 1 shall be as follows: Operation and Maintenance Sampling: laboratory fees included Reporting Total early Billed @Wuarl erly 2. Barnstable County Database Management Fee* $50.00 3. Services performed in addition to those noted, including responding to alarms,will be invoiced at per hour. 4. The cost for replacement equipment, supplies and process control chemicals will be invoiced at our cost plus surcharge in accordance with our Standard Conditions for Engagement(copy attached). 5. Additional sampling and testing, if required,will be invoiced at time and expense, in accordance with our standard rates. In the event that state or local regulatory bodies change sampling requirements and/or Operation and Maintenance requirements, the cost estimate will be revised to reflect these changes. Barnstable County assesses an annual database management fee of$50.00 for each wastewater treatment management system in Barnstable County. Each July the County.sends an assessment notice to Coastal Engineering Company, Inc_,for the systems operated by Coastal. Coastal Engineering pays the fee for the system owner and includes a$50.00 charge for this fee on your next invoice as a reimbursable expense. i COASTAL STANDARD CONDITIONS FOR ENGAGEMENT ENGINEERING TECHNICAL SERVICE CONTRACT COMPANY, INC. FIXED FEE PROPOSAL January 1, 2012 COMPENSATION FOR ENGINEERING SERVICES: Coastal Engineering Co., remain the sole and exclusive property of GEC as Instruments of service Inc (CEC) bases its compensation lot engineering services for this and CLIENT shall have no right to such documents. The CLIENT may, at project on the lee given for the project. CLIENTS are advised that his/her expense, obtain record prints of drawings, which the CLIENT will Additional Services requested beyond the Scope covered by the fee use sole and exclusive property of CEC as instruments of service and proposal or change orders attached thereto will be based upon the CLIENT shall have no right to such documents. The CLIENT may, at time input according to our current hourly fee rate schedule. Fee his/her expense, obtain record prints of drawings, which the CLIENT will proposals for professional services are prepared to the best of out use solely in connection With the project to which this Agreement applies ability based on lads available at the time of submission. and not too the purpose of making subsequent extensions or enlargements TRANsPOR1AnoN:Time and travel expenses incurred,when travel Is in thereto. the interest of the project, will be charged for in accordance with USE OF DOCUMENTS-Services performed and documents prepared by CEC CEC's fee schedule. under this agreement shall be lot the benehl of CLIENT only and may not SUBCONTRACT SERVICE5: CEC may engage subcontractors and/or be relied upon by any Thad party(ies) unless Specifically agreed to In other professionals to perform required services such as soil borings, advance by GEC and CLIENT. drilling, construction, etc That subcontractor's charge plus a service USE OF S1AxES:CLIENT, CLIENTs contractor, or any third party may not charge will be added to GEC's fee, use stakes or other markers set at the site by CEC before obtaining REIMI3URSABLE UPENSEs:Expenses will be billed at CEC's cost plus a verification from CEC that the stakes or other markers were set for the service charge. Examples of expenses ordinarly charged to CLIENT intended purpose and are In-place to the-accuracy appropriate for the are replacement equipment, plumbing and hardware supplies. and intended use. jchemical supplements for process control ELECTRoNI< FILES: Electronic files are transmitted for "Informational PAYMENT: invoices will be rendered monthly or as work progresses. Purposes only and at the request of the CLIENT or CLIENTS agent.CEC's Invoices are due and payable upon recelpt. Amounts over 30 days official product Is limited to Its signed and sealed hard copy of plans, specifications, and/or studies. The CLIENT agrees to hold CEC harmless past due are subject to a service charge of 1.5% per month 118% annually). The CLIENT agrees to pay reasonable attorney's fees end lot any damages from inappropriate or illegal uses by third parties from any any collection fees incutred in the collection of any amount owed electronic transfer of information by CEC requested by the CLIENT or hereunder and not paid when due. CLIENTS agent. CHANGE OF SCOPE- If, during The performance of services under this CONsTRucnon SERVICES: On request, CEC can provide personnel to Agreement, a change in the Scope of Services is requested on the observe construction in order to ascertain that the construction,In general, basis of an oral or written order by the CLIENT or CLIENTS Agent,or is being performed in accordance wllh GEC's plans and/or speclficatfons- is required in CEC's sole discretion by circumstances to address CEC shall under no circumstances be a guarantor of any contractor's means and methods of work and shag bear no responsibillly with respect to contingencies, or CLIENT requests revisions of the plans. CEC will perform such additional services in accordance with its lee schedule. the performance of such construction.The CLIENT and CLIENT's agent mull CEC reserves the right, at is discretion, to issue a Change Order to continue to be responsible for the accuracy and adequacy of all this Agreement- However, a Change Order is not required prior to cortislruclion periormed- rendering such services and the CLIENT agrees 10 pay lot such INDEmNIfirAnON AND LIMITATION OF LIABILITY:CEC agrees to indemnify and additional services. hold CLIENT harmless against damages and liability resulting from the SUSPENSION OF SERVICES: n the CLIENT tags to make payment of negligent acts, errors, or omissions of CEC. The CLIENT agrees to limit invoices when due. CEC may suspend performance of services under CEC's liability,resulting from errors and/or omissions In englneering design this Agreement. In the event of a suspension of services.CEC shall Information furnished to the CLIENT, to those portions of the design have no liability to the CLIENT for delay or damage caused by such prepared by CEC and In an amount not to exceed CEC'5 fee.The CLIENT suspension of services or for any consequential damages. agrees to require a Ike Iamilalion from any contractor engaged to perform work lot which CEC has provided reports,plans,and/or specifications.The TERMINATION PROVISION:This Agreement may be terminated by either CLIENT shall further Indemnity and hold CEC harmless from any lability party upon five (5) days written notice in the event of breach of resulting from the acts, errors, of omissions of the CUENT or CUENTs performance of terms and conditions of this Agreement by the other agents,contractors,or assigns.Such Indemnillwalion shag include the cost party through no fault of the terminating party. CEC shag be of defense Including without [Imitation attorneys fees, arising In any way compensated lot services performed up to the time of termination. with claims connected with any such liability excepting only such lability as may arise out of CEC's sole negligence in performance of services. INSURANCE:CEC is covered by Worker's Compensatlon Insurance and CLIENT agrees that any and all damages arising from negligent act,error, Public and Professional Liabillty Insurance. CEC will furnish or omission shag be made against CEC directly and shall not be made certification upon request. personally against any of Its directors,officers,agents, or employees. RIGHT OF ENTRY:Unless otherwise agreed,the CLIENT furnishes right- CONSEOUENrWL DAMAGES: Notwithstanding any other provision hereof, okntny on the land lot CEC to make measurements, soil tests, or CEC shall not be liable to the CLIENT lot any incidental, Indirect, or other required exploratlons. CEC will take reasonable precautions to consequential damages arising out of or connected in any way to the minimize damage to the land Irom the use of equipment,but CEC has services rendered hereunder.Including,but not limited IG,loss of use,loss not Included iri its fee the cost of restoration hom damage That may of profit;loss of business,loss of income,or loss of reputation. result from Its operations. II CEC is required to restore the land to its former condillons,the cost of doing so will be added to Its fee. STANDARD of CARE: CEC's professional services will be performed in accordance with the generally accepted engineering practices, skill, and OWNERSHIP OF DOCUMENTS: All documents, Including original care used by Similar members of the engineering profession practicing drawings,estimates,specifications,held notes,and data,are and shall under similar circumstances at the same time and in the some locality. CEC makes no warranties, express or otherwise,In connection wlh CEC's services hereunder. COASTAL ENGINEERING CO., INC. + 260 CRANBERRY HIGHWAY ORLEANS, MA 02653 TEL. 508 255-6511 FAX. 508 255-6700 BIOCLERE FIELD REPORT Project No.: 13.00 Date: c c3 6— / 4-1 Time: Installation: Sampled: Client: ( S 4t r•, 2- Service: Commissioned: Address: t �' Other: Scheduled OW: Ins ector: / Bioclere Model Number(s) 1 Odor around site Y N Source of odor? /6 Check all that apply: Mit Medium: Septic: Musty: 2 Field Testing: clarity,color,solids,odor,tests 3 a Measure sludge in prima tanks and grease traps as re uired: b Sludge depth in primary tank: Scum depth: -Q a Sludge depth: c Does grease trap need pumping? --Y— — BIOCLERE VENTS UNIT 1 UNIT 2 a Is air passing through the vent? Y N Y / N If in doubt put a small plastic bag around vent and allow to fill. b Is the fan operating and in good condition? Y N Y / N GENERAL a Apy external damage to the units ? If Yes, provide details on back. Y / Y / N b Are cover, fan box and control panel secure) locked? N Y / N C Any filter flies in the unit? YIN few/many Y/ N few/many Location of flies: d Locks/ latches/ handles. OK? Y / N Y / N e Lid gasket OK? y / N Y / N Does the fan box contain standing*water? Y / Y / N If Yes, then remove water and clean drain holes if necessary. BIOMASS CHARACTERIZATION a Color of biomass? 1)white 2)white/gray 3)gray 4)gray/brown 5)brown 6)red/brown 7)black S 8 other b Thickness of biomass 6-12 inches below media surface. 1 light 2 medium 3 heavyb_ OS NOZZLE SPRAY PATTERN a Does spray cover the entire surface area of media? Y / N Y / N If not, clean each nozzle with a bottle brush _ Does the spray now cover the entire surface area? Y N Y / N If not then: 1 remove nozzles ands ak in a bleach solution } 2 manually engage both dosing pumps for two minutes 3 replace nozzles Does the spray now cover the entire surface area? ` / N Y / N If not, consult A uaPoint, Inc. PUMPS AND CONTROL PANEL a Record dosing and recycle PUmp timer settings from control panel. Dosing Pump 1: min on: min o - min on: min off: Dosing Pump 2: min on: min off:--- min on: min off: Recycle Pump: min on )4hrs off:d- min on: hrs off: In Bioclere control panel set dosing and recycle timers to a test cycle: a Amperage of dosin um 1: amps amps b Amperage of dosing um 2: — amps amps c Am era a of recycle pump: 1 3 amps amps Are dosing pumps altematin ? one 5 L12 I N Are the timers operating ro erl ? / N Y / N Visually inspect relays for wear and record problems below. ` Ifs are components are needed contact A uaPoint, Inc. If an ammeter is not available set the timers to a test cycle as above and at the Bioclere check the pumps' operation as follows: Dosing pumps: check that um s are operating, alternating and the Pump 1 OK? Y / N Pump 1 OK? Y / N designated rest cycle is occurring. Pump 2 OK? Y / N Pump 2 OK? Y / N OK? Y / N OK? Y / N "If pumps or control components are not operating properly, record below And consult A uaPoint, Inc. RESET TIMERS TO ABOVE SETTINGS: Note any changes here: min on: min off: min on: min off: *Do not change timers without consulting A uaPoint, Inc. min on: min off: min on: min off: PLUMBING a Are the unions in the Bioclere leaking? Y ! N Y / N If yes, then tighten with pipe wrench FINAL CHECK. a Main power "on" and set toggle for all pumps to "normal" position. rYN Y / N *Alarm toggle set to the "ON" position. Y / N c Lock control panel, Bioclere cover and fan box. d If possible, record the water meter reading: REPORT SUMMARY: 5 "YJ► �© o t _ ,v x e 1 ,-zBox S l A/ELJ JD0.SM� P - [ vl L o cv r — t�►�'T - 3 I c rel ►- o � r4;17 ID/� flZjoew , 0l C � l will � p t r�4-0 SIGNATURE: D:IFORMS Curren tlTechServrces-WastewoterlBio lere Field Report.doc �[� {ql �aq ,y�JA r (� 4 i Town of Barnstable Board of Health " 200 Main Street,Hyannis MA 02601 Office:. 508-862-4644. Wayne Miller,M.D.. FAX: 508-790-6304. Paul J.Canniff,D.M.D. August 31, 2006 Mr.. Robert M.. Fitzgerald, P.E. 166 Mayflower Terrace South Yarmouth, MA.02664. WIN �'� RE94WestIlnStr�ket, Crtervfille 14It �4Q Dear Mr. Fitzgerald,. You are granted a. conditional variance on. behalf of your client, Housing. Assistance. Corporation, to construct a replacement sewage disposal. system at 940 West Main Street, Centerville, Massachusetts. The variance granted is.as.follows: 310 CMR 15.221(7): The soil.absorption system will. be located 5.5 feet below finished grade, in lieu.of the maximum.three. (3) feet allowed. This variance is granted.with the following. conditions: (1) The innovative alternative (I/A) system shall. be installed. in. substantial compliance.with.the. revised. engineered. plans.dated June.20,.2006.. (2) The professional engineer shall supervise the construction of the. I/A system. and shall certify in. writing to the. Board. of Health. that the system. was installed in substantial compliance.with.the. revised. engineered plans dated.June 20, 2006. (3) The wastewater affluent shall be tested. quarterly for pH, BOD5,. TSS,. TN, and alkalinity for a period.of two years. After a. period of two years,the.applicant shall return to the. Board for a determination on.the schedule of additional testing. This variance is granted because the existing. septic system failed and.the replacement system,. which includes. innovative alternative technology, meets the maximum feasible comp li nce standards contained within the State Environmental Code, Title 5. Sin r ly your , yern e , C. airm Q:WP/FitzgeraldHousingAsstCorp2006 �� � I �F114E Tp� DATE: CP a/ G(1 `* BARNSTABL.E. FEE v MASS. rE0 MPt A Town of Barnstable SCRED. DATE•_ .Board of Health -'Jill 200 Main Street,Hyannis MA 02601 It?, co" b&,.,oe- Office: 508-862-4644 rZ9 S'nsanan 0.mask,NS. FAX 508-790-6304 Sumner Kaufman,M.S.P.H., Wayne A Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: 'n M vSI&s'T MA1 Assessor's Map and Parcel Number: Z 4A 9 - O�6 Size of Lot: 2, Wetlands Within 300 Ft. Yes Business Name: No— — SubdivisionN SC�_,2t,vVc r ►Q[„� LONDOwIut)l� t� APPLICANT'S NAME: 1koUtitNt� Dr5hfr9fA�E CdZAA one Did the owner of the property authorize you to represent him or her? Yes _� No == PROPERTY OWNER'S NAME CONTACT PERSON { Name:}b-yhwcn M2�lyxef de-P Name: �' E Address: Akoo tit VAAVQ AT M AN"S Address: L66 *4"Rjt Q,�%L '140C. 5 YhL,6,-j ( r' /l�EC(N 'izAc,-V* wcckD ezzv o 2 c.&'dj rt Phone: ao 'i'[ Phone: BOA —1-1(0 1e55 VARIANCE FROM REGULATION(List Iteg.) REASON FOR VARIANCE(May attach if more space needed) CM lZ 316•- 125 -A-.0 6(b)t- cam=y�;,.�� r c►Kr.,r� �u�na�„�� -1 "9QXx12c'— goy Q606Clw_ —R %enQ✓LE l--GAcih..ir,4 t4STj;)&n -rcn rad&&Ta 'T�A)J �i� Tyr I :akE�g _) anAl)r -:'j2QPTll _2—gT2' 'R-sulzr V2�Qui yr il NATURE OF WORK: House Addition ❑❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System K Checklist (to be completed by office staff person receiving variance request application) Please submit copies in 4 separate completed sets. Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted.(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutteis-must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) , Variance request application fee collected {no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) E Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miner,M.D.Chairman NOT'APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Susan 0.Rask,R.S. Q:\HEALTH\Application Forms\VARIREQ.DOC Bedroom Bath Bedroom ' Bath Second Floor Plan Bath Dining Kitchen 24' Living 26' —� First Floor Plan Typical Unit Plans Sterling Ridge Condominiums Scale 1 /8' - 1'-0' June 20, 2006 Robert M, Fitzgerald, P,E, is Robert M. Fitzgerald, P.E. -- �' ,/ 60 s, ASS, rfj 166 Mayflower Terrace (70':f c q �7 r�y South Yarmouth, MA 02664 Phone: 508 776 7556 Fag: 508 760 3025 Email:fitzeeraldcaye(a),verizon.net July 18,2006 Board of Health Town of Barnstable 200 Main Street Hyannis,MA 02601 RE: Proposed UA Monitoring Plan for Housing Assistance Corporation 940 West Main Street,Centerville,MA. Dear Board Members, The following outlines the proposed quarterly operations, maintenance and monitoring of the proposed Bioclere UA treatment units at 940 West Main Street, Centerville,MA. Scope of Services The treatment system shall be operated by a Certified Wastewater Plant Operator in accordance with the requirements of 257 CMR 2.00 and the Board of Certification of Operators of Wastewater Treatment Plants and the conditions imposed by the Massachusetts Department of Environmental Protection's Certification for General Use. Operation and Maintenance A. Standard maintenance as follows: 1. Check general condition/appearance of unit. 2. Check vent flow, odor. 3. Check general condition of fan box including internal and external wiring, lock, latch, gaskets, etc. 4. Check quiet fan operation. 5. Check condition of cover locks, latches,gaskets. 6. Check and characterize biomass. 7. Check recycle pump operation,timing and effluent clarity. 8. Check dosing pumps operation,timing, and effluent clarity and spray pattern. 9. Check general condition of dosing assembly. Clean nozzles if required. 1o. Check general condition of control box including locks, gaskets, etc. 11. Check control box switches, alarms,timers,etc. B. System will be maintained quarterly(4 times per year)minimum. System Monitoring and Reporting Complete and file the results of all operation,maintenance,and monitoring activities to the Barnstable County Department of Health and Environment. Such reporting shall be performed in the manner specified by Barnstable County Department of Health and Environment within 30 days after each maintenance or monitoring event. Further, when a system operator performs a system inspection and finds that a sewage treatment technology has malfunctioning components which have compromised the system's ability to treat sewage as designed, the operator shall report on the system's status and any planned corrective actions to the Board of Health and Barnstable County Department of Health and Environment within 48 hours of inspection. Very Truly Yours, 0? Robert M. Fitzgerald,P.E. I r L10/14/2dUb 11:52 5d87757434 HOUSING ASS .CURP. - PAGE 02 A I June 14,2006 To Whom it May Concern., Robert Fitzgerald is representing Housing Assistance and the Sterling Ridge Condo Association in the project of upgrading the septic systems at 940 Nest Main Street Centerville,MA 02632, Faith Woodcock Property Manager. ,Y� Department of Regulatory Services MAM Public Health Division . Date 2639. 200 Main Street,.Hyannis MA 02601 Date Scheduled----� Aw�o.`/b- Time Fee Pd. Soil Suitability Assessment for Sewa e `a g Disnos Performed'By:�4/�E2T /LA � pal , ITLG�n,� ii �, r Wiinessed,By: LOCATION& GE Location Address �l = 'IZAL I `QRMATION Owner's Name Assessor's Map/Parcel: Address U-1 �c�.r/ s 7- L�,Y-0 rv^13 L.S1 G, `O�S' Engineer's Name�QdQ�'� NEW CONSTRUCTION REPAIR Telephone# Land Use Distances from: p Slopes(%) '- Surface Stones - _ Pen Water Body possible Wet Area $�" � j� ' �ft Drinking Water.Well -v/4 ft .Drainage Way_ (1- property Line I Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes Pen;tests,locate wetlands 9n proximity to holes) . r t�+ --- V-0+t 3� •�, �i A, --- _ - _- - _ �., -. , - - ` t,<�� ��'• ;ter,. ;, t-a'r.> -- . tu, _, � �� •. ;tom ST Parent material(geologic) c � -� Depth to Bedrock Depth to Groundwater. Standing.Water,n Hole: /tf(�i(fE. / Weeping from Pit Face_�(J d�✓E v i�(� Estimated Seasonal High Groundwater_ ZS �-"" Ij A TC.F DETERMINATION FOR SEASONAL H ✓P�e�� Method Used: �2�.Cw/ST/J/� EiQot/.�O to O C HIGH 1A _R TABLE Te-F Depth Observed standing in obs.hole: �• Depth to weeping from side of obs,hole: In. Depth to soil motties: Index Well# g Inde�eve-�--level- Ad,Groundwater AdJugtment � -,$4#_ Readin Date: AdJ,factor Adj.aroundwaterLevel,,� Observation PERCOLATION TEST _- Hole# l)nte T.Z Titne: lS" ' D t _ Time at 9" (0-o � .6 Depth of Per "'r Z L Time at V t Z-O r-1 i Start Pre-soak Time @ Time(9".6") End Pre-soak /17 } Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed:----T_ Additional Testing o Needed(Y/N)�_ Original: Public Health Division Observation Hole Data To Be Completed on Back----- ***If percolation test is to be conduc first notify within 100,of wetland,you must Barnstable Conse>�'vation Division at least one(1)week prior to beginning, notify the, Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. Consistency, Gravel) aA o'2R Alt 8-It- t.o SA 1 io�'251 41 - -1-L G t LAtM-row VW 0 "1 -i(L(o to 3c7�v c�►� Met) -To cow-jr- to ia.�v b tv v �►Q/k1FJ�. DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 4,4kjo tom 5 1 �C�1L Z-13Z G 2 "01) 'SA►30 toy 2(V l(a DEEP OBSERVATION HOLE LOG Hole# _ Depth from,, Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.). (USDA) (Munsell) •- Mottling (Structure,Stones,Boulders. !^ Consistency.%Gravel) t . r DEEP OBSERVATION HOLE LOG Hole# Depth from, v Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencX, Flood Insurance Rate Man: Above 500 year flood boundary No— Yes .22- j Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material -- Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system" If not,what is the depth of naturally occurring pervious material? _ Certification I certify that on ����(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,ex ertise and experience described in 310 CMR 15.017. Date Signature Z Zo 0,C) ( - {tjev;- I/A System Permit Summary Sheet c2t I? Site Information �S4CINS�� Town: Town Permit# Assessor Map/Parcel: _ a�t -G S S Unique Town ID # Site Address: R `-+ Ae�rV Owner Name: �±2 VtL-A ( OY" Alternate Name: Home Phone: Mailing Address: 4 &0 Mctln S4 Work Phone 5b-S )J 3-I 5`-(0b 4_4C .ncy S: Title 5 Information Building Type/Use: M L�,I rm, t �* Design Flow: 1 fl Se (gpd) Seasonal Use? Yes ❑ No�f Unknown ❑ Bedrooms: Title V N.S.A.? Yes ❑ No ❑ Unknown ❑ Lot Size: 9 "} �f- Non-standard components: Please list all components e.g. 1/A treatment unit,pump chamber,pre-and post equalization tanks, pressure distribution SAS, effluent filter, UV unit, etc., an a' a for each component e.g. quarterly, 2x/yr, annual, etc. I/A Treatment Unit Make and Model # sus 4e4-n--�U z, 1A' i`I DEP Permit Type: General Board Approval Date: 8 31 O COC Date: ❑ Provisional O & M Contract Entity: Lo cam.- E.V-\ ❑ Remedial Contract Start Date::Z 2® lam{ Contract Duration: s - ❑ Pilot Unit Installation Date: Unit Startup Date: DEP Permit ID#: Influent/Effluent Monitoring Requirements and Water Quality Limits Please indicate water quality parameters that must be monitored and any town mandated water quality limits;if no limits are shown, we will assume parameters and effluent limits specified in the system's DEP approval will apply. Effluent PH BOD5 ❑ CBOD TSS ❑ TN _ Nitrate Nitrite El Ammonia ❑ TKN Fecal Coliform Total P� Organic N Organic P ❑ TDS ❑ Oil/Grease ❑ Conductance ❑ Alkalinity Water Usage ❑ Temp. ❑ Monitoring Schedule: Other Applicable Limits: Influent pH ❑ BODS ❑ CBOD ❑ TSS ❑ TN ❑ Nitrate ❑ Nitrite ❑ Organic N ❑ Ammonia ❑ TKN ❑ Fecal Coliform ❑ Total P ❑ Organic P ❑ TDS ❑ Oil/Grease ❑ Conductance ❑ Alkalinity ❑ Water Usage ❑ Temp. ❑ Monitoring Schedule: Other Applicable Limits: BCDHE Tracking # Please return this sheet to: FAX: 508-362-2603 Email: bciatech@cape.com New I/A System Permit Summary Sheet Site Information Town: Barnstable, Town Permit# 2007-110 Map/Parcel: 249-055 Unique Town ID# Site Address: 940 W. Main St. Centerville, MA 02632 Owner Name: Housing Assistance Corp Alternate Name: Sterling Ridge Home Phone: Mailing Address: 460 Main St., Hyannis, MA 02601 Work Phone: 508 771 5400 Title V Information Building Use: Condominiums Design flow: 1980 Seasonal? No Bedrooms: 18 Title V NSA? Lot Size: 3 sc,J-4- 2 • z Non-Standard Components 8 bedrooms/System#1-replace failed leaching systems. Install new Bioclere Model 16/15. Existing septic tans to remain. 10 Bedrooms/System #2 -install new Biocelre Model 16/19 I/A Treatment Unit Make & Model: Bioclere Model 16/15-15/19 DEP Permit Type: 3General Approval Date: 8/31/2006 COC Date: X Provisional O&M Entity: A& B Canco, 350 Main St. W. Yarmouth, MA X Remedial Contract Date: Contract Length: X Pilot Install Date: 4/25/2007 Startup Date: DEP Permit ID# fj �d _ Influent/Effluent Monitoring Requirements and Limits Effluent Ammonia IkalinityX BOD5X CBODX ConductanceX F. ColiformX NitrateX NitriteX Oil/GreaseX Organic NX Organic P X , H X TDS X Temp.X _ TKN X <X Total P X TSS X Water Usage X MonitoringSchedule` Quarter) Other Limits: 'v " �� 2 Influent Ammonia X AlkalinityX BOD5 X CBOD X Conductance X F. ColiformX _ NitrateX _ Nitrite _ Oil/GreaseX _ Organic NX Organic P X _ pH X _ TDS X _ Temp.X _ TKN X TN X Total P X TSS X Water Usage X --, Monitoring Schedule: Other Limits: Additional Comments/Information Office Use Only. Tracking#: Date Entered: Entered By: YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1`°FL., 367 Main Street, Hyannis,MA 02601 (Town Hall) DATE: 0 1 GZOt o Fill in please: ' ! APPLICANT'S YOUR NAME/S: I/f e-i n� Si VC1— / r° BUSINESS YOUR HOME ADDRESS: U.)p5E: mph. pr! TELEPHONE # Home Telephone Number OS NAME OF CORPORATION: G S AcNsc " NAME OF NEW BUSINESS TYPE OF BUSINESS L_ko h P('(vc =tVAN C IS THIS A HOME OCCUPATION? _YES NO C6 N—(C- jL VI C-LZ µ A 21,.2— ADDRESS OF BUSINESS ��O w MIki t� L7 'u f '� S MAP/PARCEL NUMBER [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner.of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** Q COMMENTS: CIO � -n 2. BOARD OF HEALTH ov This individual has n in ormed of the p r it requirements that pertain to this type of business. orized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION W �� SEWAGE # O GE __ __ASSESSOR'S MAP & LOT IIV ALLER'S NAME&PHONE D10. f tNC SEPTIC TANK CAPACITY Xrs7tN 7—an S, iEACH>rrc>~Acu rrY: (type) &-5�a��< S .(size)U) 33'Si�l3 2` NO.OF BEDROOMS" BMDER OR OWNER �`�` ��+�� / a{�s!" �' • PERMTTDATE: —! ? COMPLIANCE DATE: Separation Distance Between the: ! . I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility k r Pl*n Feet Private Water Supply Well and Leaching.Facility (If any wells exist on site or within 200 feet of leaching facility) �� Feet j Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) M Feet I Furnished by e�-- n 1 g' t i I I I http://issgl2/intranet/propdata/prebuilt.aspx?mappar=24905500A&seq=3 2/4/2014  , COMMON WEAU1.1 I Oil' MASSACHUSE'I"1'S 1 EXECUTIVE OFFICE OF ENVIRONMENT/1L AFFAIRS � DEPARTMENT OF I NVI:RONM.ENTAL. PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 Z _ TRUDY (11OXE 350 MAIN STREET Secretary ARGEO PAUL CE LUCCI A WEST YARMOUTH, MA vnvlD B. sTRuxs Governor � 508-775-2800 h► G®(commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 249 PAR 055 PROPERTY ADDRESS: 940 WEST MAIN STREET, HYANNIS ADDRESS 4 DATE OF INSPECTION: JUNE 26, 2000 HOUSING ASSf 9N� NAME OF INSPECTOR : JAMES D. SEARS STERLING RIDGE I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) 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 information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAI;pyy INSPECTORS SIGNATURE: DATE: JUNE 27,2000 The system Inspector shall submit a of thi!inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: REPORT ONE OF TWO FOR UNITS 1 THROUGH 4 SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION.OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION (continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 INSPECTION SUMMARY: Check A,B, C, orD: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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 repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 revised 9/2/98 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER �i revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 D]SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No g 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in'accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)115.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 880 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 8 Number of bedrooms(actual): 8 NOTE:2 BEDROOMS PER UNIT Total DESIGN flow Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): N/A Sump Pump(yes or no): NO Last date of occupancy: N/A COM M ERCIAUI N DUSTRIAL: Type of establishment: Design flow: Gpd(Based on 16.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping NOTE: TANK PUMPED AFTER INSPECTION-MAINTENANCE PUMPING BY A&B CANCO 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1986 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 s revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: 3' Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 2,500 GALLONS Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 50" Scum thickness: 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: 19" How dimensions were determined TAPE Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) MAIN TANK AT WORKING LEVEL.INLET TEE,OUTLET TEE,INLET COVER T STEEL AT GRADE.OUTLET COVER 18" CEMENT AT GRADE. GREASE TRAP: N/A (locate on site plan) Depth below grade: P 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26,2000 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D-BOX IS 16"X16",64"BELOW GRADE. ONE LINE IN,TWO LINES OUT.18"CEMENT COVER AT GRADE. 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.) revised 9/2/98 9 I L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26, 2000 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TOW(2)1,000 GALLON PRE CAST PITS,PITS ARE S BELOW GRADE.BOTH HAVE 30"WATER NO HIGH WATER STAIN LINE. BOTH HAVE 18"COVERS AT GRADE. CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26. 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) O t „\ 6 i H/ Y revised 9/2/98 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 940 WEST MAIN STREET, HYANNIS Owner: HOUSING ASSISTANCE-STERLING RIDGE Date of Inspection: JUNE 26, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 23.8 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) USGS WELL AIW 230 AT 23.8 revised 9/2/98 12 COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP ®� PARCEL LOT _... .�.M TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIONECTION Property Address: /�CLLXd, A "A- + F Owner's Name: ' (Uk QGC1Y�o C=:) Owner's Address: ��'_. Date of Inspection: C ry ; '''p cn cn Name of Inspector: (please .rint (^� x-t Company Name: E -0 Mailing Address: ry rxr Telephone Number: 7J. , CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority r Inspector's Signature: Date: The system inspector shall sub rt 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 I0,000 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 ****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 tinder the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page F t s Page 2 of 1 I 7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: b)V la A-Cl Owner: YAPr Date of Inspection: Inspection.Summary: Check A,B,C,D or,B/ALWAYS complete all of Section D A. System Passes: i Fha`ve not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or mores stem components as described in the Conditional Pass section need to be replaced or y P P 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 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. 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 Page 3 of 1'1 OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM PART'A. CERTIFICATION(continued) Property Address: Owner: Date of Inspection: (� 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is func tioning ctioning 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A,copy of the analysis must be attached to this form. 3. Other: { Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J ,4 Owner: Date of Inspection: C D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the-following for all inspections: �L 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 ''/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 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 coliform bacteria and volatile organic.compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. 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. 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 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. 4 Page 5 of 1 1 } OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the f..ollowing: Yes .0 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 ? — V"'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? t/ _ Were all system components, excluding the SAS, located on site V — 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 fi•om 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)] S Page 6.of 1 I OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM•IlVSPECTION FORM PART C SYSTEM INFORMATION Property Address: ` ) Owner: Date of Inspection:_ 1~LOW CO DITIONS RESIDENTIAL Number of bedrooms(:design): . Number of bedrooms(actual): DESIGN flow basedon 310 CMR 15.203 (for.e ample: 11:0 gpd x#of bedrooms): Number of current residents: Does residence.have a garbage grinder(yes or no): 100 Is laundry on a separate sewage system (yes or no):&.[if yes separate inspection required] Laundry system inspected(yes or no):a Seasonal use: (yes or no): A)o . . Water meter readings, if available(last 2 years usage(gpd)):2-�900 0�-`Pmiv Sump pump(yes or no): O Last date of occupancy: COMMERCIAL/INDUSTRIAL 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: �vs-L Was system pumped as hart of the i spection{yes or no): ' If yes, volume pumped: gallons--Iiow was quantity pump.ed deteriiiined) 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) Irmovative/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 c mponents, date installed(if known)and source of information`. Were sewage odors'detected when arriving.at the site(yes or no): 6 C , Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nn SYSTEM INFORMATION+ (continued) Property Address: t . Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of constriction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction liner Comments(on condition of joints, venting, evidence of leakage, etc.): 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 certificate) Compliance(yes or no): (attach a copy of /L Dimensions: _l ��( o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z-� Scum thickness: D 1 Distance from top of scum to top of outlet tee or baffle: 4 Or lle..c° Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: p► � � Comments(on pumping recommendaations,4nlei and outlet tee or baffle condition, structural integrity, liquid levels r rated to outlet invert, evi nce of leakage etc.): GREASE TRA (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.): I Page 8of11 OFFICIAL,INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspection: C,C 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/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 akag,e into or out of bo , e i PUMP CHAMBER (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 I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: , Date of Inspection: (� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type eaching pits,number: 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. CESSPOOLS:/' (cesspool must be pumped as part of inspect ion)(]ocate 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY (locate on site plan) Materials of constriction: 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 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) j Property Address: 0 Owner: 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. �3 a 9L O b()0 anon )COO a 11e�r� 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /,l , SYSTEM INFORMATION(continued) Property Address: �� d� Q eQ� 1 Owner: Date of Inspection: C/ (1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: 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: r Ole ZI AVY . 11 x A. ;y R 1e44r� `t �r % 'LNRF i{d J,Jak f Gfi . 7� h 1 l �di V i y 11 f^s�lPtk'Y +F�3,L.1 Permit Number. Date. Completed by: HIGH GROUND-WATER LEVEL COMPUTATION - l 1 a =:Site Location: `Z(/ Lot No. Address: Y ifs0# Contractor: � o� Address Notes: 1 STEP 1 Measure death to water table rlJ� tonearest 1/1Oft. .............................................................................. .Date �7 _ month/day/Year ' 3l STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Appropriate index well...................................../...:.. _/ © Water-level range zone .................. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .............................................................................................. / Figure 13.--Reproducible computation form. I 15 el i I�P�LED �. � ]ARN I t`S rJl'vLL. �5®� OCT 2 " LOT � TOWN OF B HEALT DATE 10114104 PROPERTY ADDRESS 940 'V"t Main Staeet Kyann.iZ Ma 02601 On the above date, the-septic system at the address above was Inspected. This system consists of the following: 1,. 1_2009 ga$eon zept.ic tank 2.. 1- Dist/Ligation goz. 3. 2-1000 ga 22on eeach.ing p itz.- Based on inspection, I certify the following conditions: 7h.is iz a T.itie Five Septic hyztem. Septic 6y6tem .ib .in Kydaaaiic laiialte. Both e ch.ing pitz ate SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 soft JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775.3338 775-6412 • I� r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRUNUMAL AFFAIRS DuARTMENT OF'tNiVlltOl4MtNTALPTtOTtOTION d Y r .. TITLE 5 OFFICIAL INSPECTION FORM—•N0T1OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A - CERTIFICA'TIUN. Property Address:Q 4 # N ri i n .S f." l yann.i.6 lla 02601 Owner's Name: Ko,su.inc S.,ez.Ung Ridge Owner's Address: 460 ldesi- Naln Stapp_;t Kuanniz Date of Inspection: 1011104 Name of Inspector: (please printy20 i e2.t /,¢02-i l-,L Company Name: 11 a c o 2 z;&' ,.on Z t c. Mailing.Address: en ezv.c e, ab�a. 02632 Telephone Number: 5 0 8—7 7 5-;,3 3 3 CERTIFICATION STATEMENT 1 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.' sewage disp osal systems.I am a DEP approved system inspector pursuant to:Section.IS340.of-Title 5(31-6 CMR,15:000). The system: Passes -Conditionally Passes Nee Further valuation.by the Local Approving.Authority it � Inspector's Signature: / �' Date. Jo The system inspector shall submit a copy of this inspection reporrIo the.ApprovinS 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�owher.shali submit the Teport 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 ****This report only describes conditions at tho time of inspectimr 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. I . Page 2 of 11 OFFICIAL INSPI'CTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM,INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 940 14,64 Pdain S.taee.t IlUanni-6 Na Owner:110ZU-iny 7676 ance ea .cng .idge Co., Date of Inspection: 1 0/1/0 4 Inspection Summary: Check A;B C,D or.E/ALWAIVoomplete=all of Section.D A. System Passes: NO _ 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: Se/2.t:ic hU,3tPM iA in r].i;.P_unv- nAW RPe7rhina n.nva nvvd -#o PP-. in AIriPPor/_ B. System Conditionally Passes: n o One or more system components as described in the"Conditional Pass":section need to be replaced:or repaired.The system,upon completion of replacement or repair,-as approved by the Board of Health,will pass. r Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. no The septic tank is metal.and.over 20 years old*or the septic-tank(whether metal.ornot)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 0A..as.approved by theBoard of Health. *A metal septic tank will pasi 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: no o 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,sett led.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: rz o 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: Page 3 of 11 OFFICIAL INSP-ECTION FORM-NOT VOR VOLUNTARY ASSES-SMENTS SUBStWACE SEWAGE O'ISFOSAL SYSTEM INSPtCTI6NIFORM PART A . . 'CERTIFICAIION'(6ontinued) , Property Address9 40 Glee Main s t2eet a n Ownerfloha inq A•s�sz ante e2 cn y Ridge Date of Inspection: 10/1/0 4* e C. Further Evaluation-is.Required by the Board of Health: no Conditions.exist whichxequire further..e.valuation-by.the Board,of fleaith:in order.to:determine if-the system is failing to protect public,health,.safety or the environment. . s 1. System will pass unless Board-of Health detertnines4li accordance with 310.CMR 15:303(I)(b)that the system is-not functioning in.a mariner which-will.protect public health,safety anSl.tbe.enuironment: as Cesspool or privy is within;50 feet of asurface water n cesspool or privy is within 50.feet ofs bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board-oi Health(and Public Water Supplier;If any),detefmines:that the system is functioning in a mariner that proteets the:pttblic health,safety and environment: has a septic W*and soil absorption system•(SAS).:and the SAS is within 100 feet.of a The system surface water supply or tributary to a surface water supply. no The system has aseptic tank and SAS and the SAS is!within a Zone I of a public water-supply. -the SAS is within:50 feet of a private water.supply well. no The system has a septic tank and. AS and n r) The system has a septic tank and SAS and the7SAS is less than 100 feet.biit 50 feet oF.zriore frorif 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 coli€orm bacteria and volatile organic coiiipounds indicates that the well is free from-pollution from tfacility aat ni other the presence of arhmonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided failure criteria are triggered.A copy of the analysis must be.attached to•tl}is form. 3. Other: Page 4 of 11 OFFICIAL INSP.ECTIO- N FORM-NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address940 Glest Plain St2eef H11anni-6 Na Owner:flo' u ' .ing aidge Date of Inspection: 1 0/9/0 4' D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to.each.of the:following:for_all Yes No X Backup of sewage-Intcrfat'Aity.or system component due to overloaded or clogged SAS..or.cesspool X Discharge.or ponding of effluent to the surface©f the:,gound 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 WA h.p 46 ' X _ )Liquid depth in oii#6el is less thank"below invert or available volume is less than%.day flow L_ Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion.:of a cesspool-or privy is within a.Zone!l of a.public.well.. _ X 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 colifortn bacteria and volatile organic compounds indicates that the well is free from pollution;:fr..om:that:facllity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm,provided that no other failure criteria are-triggered,.A copy of the analysis must be attached.to this€orb.] ye- (Yes/No)The system fails.I have determined that one or:.more,ofae: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.afaeility,with a design flow of 1.01000 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 ,x the system is within400 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 Qnterim 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. 4 Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS gLiUSURFACE SEWAGE DISPOSAL:'SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:940 lde.,6t Main Staeet Ownerfo.suinU Azziz ance/Ste./Liin'g R-idge Date of Inspection: r1^01-- 1-104 Check if the following have been dpne You must indicate"yes"or"no"ar#o each of theoilowing: Yes No — provided the owner,occupant,or Board of Health X pumping information was 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 tlt�inspection? X Were as built plans of the syste n,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? — �.n Were all system components,'e2cluditig 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 of scum 7 ._ 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 determhned based on: Yes no X _ Existing information:For example,a plan at the Board of.Healtll. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximAtionof distance is unacceptable)[310 CMR 15.302(3)(b)] Sir ,• ,� • 5 Page 6 of I I OFFIC IAL 94$PECTIU-N..'I IQRM%-NOT FOP.'VOLUNTARY ASSESSMENTS SMSURI ACE SMAGE DISROSAL SYSTEM INSPEET IDN:FORM PART-C SYSTEM INFORMATION Property Address: 940 /Meet ft iri Street Unite 5-9 Hu.aan.i,6 Owner;qo u i g Ridgd Date of Inspection: r FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desigq):1A. :Number of bedrooms.•(actual):10 DESIGN'flow-based on 310 CRC 15.10 ':(for a ample:'11''gpd x#-ol'bedroiitns):1 OX 110-110 0 GP D Number of current residents: .: 15 Does4e$idence have a garbage grj$der(yes or no): n o Is laundry on a separate sewMe.system-(yes or.no)t o [if yes sepanjte inspection required] Laundry system inspected(yes or no): ri o Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)):S e e a t t a c h e d N g 6 A Sump pum (yes or no):a& Last date of occupancy: p a e e en t COMMER61ALf3 bUSTRIArL Type of estab '_ 't: Design flaw. •7 on310 CMR 15.203):. I _god Basis.of d iga' low(seats/,persons/sgft,etc.):, NN�A Grease trap•present(yes or no): Industrial waste holding tank present.(yes or no):N4 Non-sanitary waste discharged to the Titl6Vystem•(yes or no): N4 Water•.meter readings,if available: Last•'dite of occupancy/use: .NA OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: Not ay.iaiagie Was system pumped as part of the inspection(yes or no): n o If yes,volume pumped:_gallons--How was.quantity pumped determined? Reason for-pumping: TYPE OF SYSTUM X Septic tank,distribution box,soil absorption•system _Single cesspool —Overflow cesspool Privy _Shared system.('yes or no)(if yes,attach previdus inspection records,if any) _Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) y —Tight tank. Attach a.copy•of the DEP.approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 20 uea2e Were sewage odors detected when arriving at the site(yes or no):n o 6 Page 64, Wate2 Uzage UNI7 5 2002=75, 000 gaeionz G.� D.,-205.47 2003=65, 000 ga.Qeonz q.-P D.- =178.,08 UNI7 6 2002=51. 000 gai.eone q.,l D.�=M. 2e 2003=46, 000 ga2.eon,3 G.-P D' =126,.02 UNI7 7 2002=75, 000 gaeionz q.-P D.- =205. 47 2003=80, 000 ga.teonz G. i,,D., =219, 17 UNI7 8 2002=40, 000 gaeionz G.-i,-D.• =109. 58 2003=34, 000 ga22on.6 G. P.-D. =93.. 15 IINI7 9 2002=72, OQO gaiion,3 G.•P,,D.- =197. 26 2003=52, 000 ga e eons D, =142.46 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 940 4le.6.t Na-in llnit 5-9 ann.ia Na Owneriioua.ing 4.6,6.iziance/ Ste2.e.ing Ridge Date of Inspection: 10/1/'0 4 x BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X 40 PVC other explain): Distance from private water supply weA or suction line: 10 f,e t Comments(on condition ofjoints,venting,evidence of leakage,etc.): '411 'o'.int s ate t i /zt no �� nos o� leakage. SEPTIC TANKV a-s(locate on site plan) 2000 ga Q.Q o n tank Depth below grade: a_____c a a d e Material•of construction: X concrete metal,____fiberglass---Polyethylene — ' If tank is•metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 12'LX 6' 6"1VX J'fig Sludge depth: t a a.c e Distance from top of sludge to bottom of outlet tee or baffle: 2 4" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: e v e n Distance from bottom of scum to bottom of outlet tee or ball�" How were dimensions determined. m e a s u 2 e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): grity,liquid levels Puffl!12 .tank. annua.2.Q In-2et 'f out pet tees ate .in /?.lace., GREASE TRAP:NO(locate on site plan) Depth below grade: - NA Material of construction: concrete_metal fiberglass_polyethylene_other (explain): NA _ Dimensions: NA, Scum thickness: tiA Distance from top of scum to top of outlet tee or baffle: 'NA Distance from bottom of scum to bottom of outlet tee or• l—baff e:7 Date of last pumping: NA ,► Comments on( pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,,liquid levels as related to outlet invert,evidence of leakage,etc.): g2eaze t/Lag i.6 not 1211 e sent. TWA i Tnavwrfinn Fnrm 7 L f Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SV99—V F A,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PrvpertyAddress940 GJeit Plain Staeet unit6 5-9 Owner. o,6uin,I �zz�al ance e2i.irng /Ridge Date of Ibspection: 1011104 TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspettion)(locate on site plan) Depth below grade: NA Material of construction: concrete metal fiberglass--_Polyethylene other(explain): NA. Dimensions: NA. Capacity: NA • gallons Desi A gn Flow: � N gallons/day Alarm present(yes or no): N4 Alarm level: NA Alarm'ut working.order(yes or no): Date of last pumping: NA Comments(condition of alarm and float.switches,etc.): Tight o2 ho.ed.ing tankz ate. not /22e.6en` ;t DISTRIBUTION BOX: Ye-3(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _yes 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.): Dii6tlti.gu.t.ion Sox ha.6 2 &1-e2aiz.- 7he2e ins ev.ideace o�e ;6oiidh caa2u overt., No evidence o leakage in o2 out o ox., PUMP CHAMBERNO (locate on sife.plan) Pumps.in working order(yes or.no):NA Alarms in working order(yes or no):/77 Comments(note condition of pump chamber,condition of pumps and appurtenances, ett;.): P umR ehamle2 .iz not pzezent.- 8.' Page 9 of 11 OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IIISPOSAL SYS'I?EM INSPECTION FORM PART<C SYSTEM INFORMATION(continued) PropertyAddress:940 blezt Main St2ee.t Unitz 5-9 HUe7nn.iS No Owner:.Kozu.inca Az.sizlance/ S.te22.ing Ridge Date of Inspection: 1011104 SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation not required) If SAS not located explain why: Located see Rage 10 , Type X 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: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Leachin �n;Li naa .in l74d1inij P i r aea Piing , �ni 06 jinn i.inf vege.taiion Li anama.P -- CESSPOOLS:No (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: N4 Depth-top of liquid to inlet invert: NA Depth of solids layer: NA Depth of scum layer: N,4 Dimensions of cesspool: NA Materials of construction: NA Indication of groundwater inflow(yes or no): N,4 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Cei.612oo4,6 ate no nP.sOR PRIVY: 120 (locate on site plan) Materials of construction: NA Dimensions: _ Depth of solids: N 4 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l2.i.ny i,3 not 2eZen;t.' 9 Page 10 of 11 ... A OM . INSPE �'IQN `QRM>rtNOT FOR?V'OL;JNTAR'St,ASSESSIVIENTSr SUBSUMACE•`SEWAGE1�ISPOSA SYSTEIN .INSPEG�'T30�i:FQR11 PART C #� SYSTEM 04F`-ORMATLON(pontinued)' Property. Address: 940 klezt Plain. Sweet Lln��h 5-9 K angi� Ma 02b01 Owner�y 0a,6ing -6 -3 anc 2,eing Ridge Date of Inspection: 10/1 04 SKETCH OF SElWAGT'DISPOSA,L 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. vv � % .... • � I o Osa �. v I 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress:9.40 Yezt Main Staeet lln.it s 5-9 yarMi.6 Rd Owner:hohu.ing 4,3.6h.i,3tanee/ Steai.ing Ridge Date of Inspectional 0/1/0 4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2 5 ' 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: Observed site(abutting property/observation hole within 150 feet of.SAS) Checked with local Board of Health-explain: Checkedwith local excavators,installers-(attach-documentation) __,,,,Accessed USGS database=explain: You must describe how you established the high ground water elevation: Gahezty 9 Nieie2 Nodee 12/16/94 gan.und ;,,rifoo r'901'a Aga 401"2, 9 7echn.icai gu.P_.Ppi n 92-nnn- Tup of Ground Leaching Pit 1:�eet r—� Groundwater: 15Fe.et Below Bottom of pit 27' High Groundwater Adjustment 1.8 ft per 111tinepterr Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet: 11