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HomeMy WebLinkAbout0057 ALICIA ROAD - Health 57 Alicia Road -�d t-114-��21 92 a I� a 4• t .y ll ' �0 �� TOWN OF BARNSTABLE �!I LGCATION /�I f�-f'q R SEWAGE # VILLAGE f����/►�Il S ASSESSOR'S MAP &LOT •r. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f�� GA1- LEACHING FACILITY: (type) 6�X C (�.Ts (size) trw NO. OF BEDROOMS 3 BUILDER OR OWNER S7zvt, 90211+ AA PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility) Feet Furnished by a„ I . yo 3 t9 Ya y y S yr 3� TOWN OF BARNSTABLE LOCAliON 7 /T[�C�G 4� SEWAGE# yJL(,puE /C[ ASSESSOR'S MAP&LOT JNSTAI LER'S NAME&PHONE NO. SEPTIC TANK-CAPACITY . D LEACH NG FACILITY:.(type) r i (size) -C9 NO.OF BEDROOMS 3 BMDER OR OWNER PERMITDATE: ' COMPLIANCE DATE:. Separation Distance Between the: Maximum Adjustc4 Groundwater Table to the Bottom of Leaching Facility- Feet I i' t Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility)', Feet Edge of Wetland and Leaching Facility(If any tlands exist within 300 feet f leachin�jfacili Feet •,Furnished*by <� �� �'� � � - f t , f O � � , 1 � u� .► � (l _. -� � � � � � � � � � � fi P � � Q � �l � � � Q r� . C,J � � r '� � W o oQ 4� b, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 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. A. General Information 1. Inspector: Iva Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furher Evaluatio the Local Approving Authority 5-3-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t 1� t5insp official document•03/08- Title 5 Official Inspection Form:Subsurface SewIM.spoSystem•Page 1 of 15 I • L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 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: System is in good working order with no sign of failure. Recommend pumping annually for maintenance and to prolong life. 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. 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 t ❑ obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced - ND Explain: I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 M303(1)(b)that the-system is not functioning in a manner which will protect public health, safety and.the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ . The system has a septic tank and soil absorption system (SAS) and-the SAS is within 100 feet of a surface water 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. t5insp official document-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than 1/ 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) , D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 El Elthe 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 a Commonwealth of Massachusetts 1 _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µM 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection r 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? • t ® ❑ 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: k r ❑ ® Existing information. For example, a plan at the Board of Health. ® ElDetermined 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)] ` M t t5lnsp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate.1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available�(last 2 years-usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2-10 Date Commercial/Industrial Flow Conditions: .Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): I Approximate age of all components, date installed (if known) and source of information: 1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): t Depth below grade: 24 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of,Com.pliance? (attach a copy of certificate)• ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal ti Sludge depth: 12 Distance from top of sludge to bottom of outlet tee or baffle 20 ' Scum thickness 0 . Distance.from.top.of scum to top of outlet tee or baffle 6 16 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 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.): I Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 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): t5insp official document-03108 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today,Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every �H annis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 gal ❑ 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.): Leach pit in good condition with no sign of back-up. Leach pit 4 had water below invert with stain line at invert. Leach pit 5 was empty at inspection with stain line at 16" below invert. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Alicia Rd Property Address Bank Owned (Contact David�Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate onn, site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp official document,-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. -c- - /5) Q 6, t5insp official document•03108 Tore 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 a Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Alicia Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-3-10 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: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 20'. ' t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i. Town of Barnstable cf SHE T� Regulatory Services &UMSIAUM Thomas F. Geiler,Director 9� o 6 Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 15, 2009 Attn: Hyannis Fire Department Health Inspector Donna Z. Miorandi, R.S. conducted a housing inspection (on 6/11/09) in response to a complaint. The State Department of Public Health has not promulgated regulations for CO detectors into 105 CMR 41.000, the State Housing Code to date. It is the policy of the Town of Barnstable Health Division to take similar actions for CO detector violations as is currently required for smoke detector violations (under 105 CMR 410.482) which is to notify the Fire Department if there is a violation, or possible violation observed. The following property had possible smoke detector(and\or CO detector) violation(s): 57 Alicia Road,Hyannis,Assessors Map-Parcel: (292-262): No smoke detectors provided for down stairs bedrooms and no CO detector in basement. (Building department has issued an exit order for the basement). o Q 0 Donna Z. Miorandi S.-Health I ispector QAOrder letters\Housing violations\Rental ordinanceUire ViolationsTIRE TEMPLATE.doc ST- • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION [RECEIVEDAY 3 0 2003 OF BARNSTABLETITLE 5 EALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 57 Alicia Road Hyannis, MA 02601 Owner's Name: Steve Houlihan Owner's Address: Date of Inspection: May 20, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map:292 Mailing Address: P.O. Box 49 Parcel.262 OstervW MA 02655-0049 Telephone Number: (508) 862-9400 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 Fai Inspector's Signature: Date: May 24, 2003 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 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 i 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. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 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(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water 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: 3 Page 4 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/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 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. [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.] No (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 System: 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 j Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Alicia Road Hyannis, AM Owner: Steve Houlihan Date of Inspection: May 20, 2003 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 r i Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -82,500,gals.; 2002-68,250,gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: 912212000 PerTreatment plant Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: sallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Ori,ginal 25 years-Ne►wr pit added in 1994 Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan . Date of Inspection: May 20, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels , as related to outlet invert,evidence of leakage,etc.): 7 i i Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 TIGHT or HOLDING TANK: None (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: Even Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (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 pump's and appurtenances,etc.): I 8 I . Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Inn ovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The original pit(#4)was full. The bottom to grade was 9'and the cover was 30"below grade. The newer pit(#5)had 1'of wa1 on the bottom. The scum line was T up from the bottom. There were no signs offailure. The cover was 15"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) I 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: None (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.): it 9 f Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 Map:292 Parcel:262 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. [< n It a O yo iy 3 10 i Page 11 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Alicia Road Hyannis, MA Owner: Steve Houlihan Date of Inspection: May 20, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. I1 i COmmonweotWl Of MOS=huSetts ,John Grad ExeeuWe Office of ENrorrmi tal Affairs D.E.P. Title V Septic hispector Department of P.O. Box 2119 Environmental Protection Teatic. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM AP8ORT O CERTIFICATION TOW,NOf `5 1997 HiiAHI Ilk � Property Address: 57 Alicia Rd. Hyannis Address of Owner: Date of Inspection:4123197 (If different) 4P Name of Inspector:John Graci Bob Wolfinger:23 Uncle Willies Way Hyannis 'v lit. Company Name,Address and Telephone Number: 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 This Inspection Is based on criteria defined In Title V Condition Ily Passes code 310 CMR 15.303.My findings are of how the system is performing at the time of the Inspection.My Inspection does _ Needs F h valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature: Date: 4123197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: Q� x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank 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. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57AIlcland.Hyannis Owner: Bob Woinnger:23 Uncle Willies Way Hyannis Date of Inspection:4123197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage in 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 overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Alicia Rd.Hyannis Owner: Bob Wolfinger:23 Uncle Wlllles Way Hyannis Date of Inspection:4123197 D) SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped j 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 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. I 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 57 Alicia Rd.Hyannis Owner: Bob Wolfinger 23 Uncle Whiles Way Hyannis Date of Inspection:4123197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. Na 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,excluding 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. I i (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Alicia Rd.Hyannis Owner: Bob Wolnnger:23 Uncle Willies Way Hyannis Date of Inspection:4123197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: n1a Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: Na Design flow:U gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: Original Approximately 25 years with new pit Installed in 1994 Sewage odors detected when arriving at the site: (yes or no) No Y , (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5T Allcla Rd.Hyannls Owner: Bob Wolfinger:23 Uncle Willies Way Hyannis Date of Inspection:4123197 SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: LII'6' H5'7"WW4'10" Sludge depth:2' Distance from top of sludge to bottom of outlet tee or baffle: 25' Scum thickness:5' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 13• 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.) Septic tank and all components are structurally sound.Recommend pumping system now and then maintained every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: rda Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle:n1a 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.) nla I (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Allcla Rd.Hyannis Owner: Bob Wolfinger.23 Uncle Whiles Way Hyannis Date of Inspection:4123197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nla Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design flow: nla gallons/day Alarm level: nla I Comments: (condition of inlet tee,condition of alarm and float switches, etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n►a Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rVa I i (revised 11115195) 7 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Alicia Rd.Hyannis Owner: Bob Wolfinger:23 Uncle Willes Way Hyannis Date of Inspection:4123197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits,number: 2-1,000 gallon leach pits leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number, length: n1a leaching fields, number, dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflows are structurally sound and functioning properly. I I CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a I (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Alicia Rd.Hyannis Owner: Bob Wolfinger:23 Uncle Wlllles Way Hyannls Date of Inspection:4123197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 13 � A Cb) �pen� 6C 3� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 _ - TOWN OF BARNSTABLE LOCATION 1 Q t I C'k a lRb' SEWAGE # VILLAGE y Q yjt� j S ASSESSOR'S MAP 6z LOT.� - 3a 7 INSTALLER'S NAME & PHONE NO. Car SEPTIC TANK CAPACITY D©O LEACHING FACILITY:(type) P° (size) lBY�D NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER So r�T l i DATE PERMIT ISSUED: to q. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I r p 9' + 35• N10 AJ ) No Fns..S^dJe......_ �L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ppliratiun for Diupugal Works Tiltu ararttun Permit Aystem tion is hereby made for a Per�i to Constr ct 1 �® or Repair ( ) an Individual Sewage Disposal ��IIJ�JJ N ti Ck ........... -.. ..._....................................... ------------- ............. Locaf n-A dress or Lot No. . .3.........- � � °�. �.�: ...... � ��C�•� -r.----- ---------------------------- wn �((� , nC `�••••••••---- Addre(ssr� ,�„� ---�-•lam-' -•--'t- •' 7••---...-- _10 Insta ler Address Type of Building Size Lot............................Sq. feet .-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building No. of persons__---_-__-__•_______________ Showers — Cafeteria Q' Other fixtures ................................ . --------•---------..•••-•-•--------•••-------•••-•-----•-•--••......-•------••-...........-------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity_._.........gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................... rZ., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a \� -- ••--•------------------------•.........------------•---•••••••...--•--•......................................................... O Description of Soil.......... F x`-� __ U ---------------•-••••-•••-•---•-••-•--••------------------------------- .......----------------------------------...-•-•-•------ W -••--•-----•----------------------•.._..•--••-••--•-•---•-----••--------•---••--•--•••----------•---•--•----------------•-•-----••......... ......................................................... Nature of Re airs or Alterations—Answer when a icable.___ U P / P ^1 ? ------------•---�pC'---L"t-�........ ..-•----•---...---•-----•----••------••-----•-•-•----------{ -- 1 .............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp ante ha ben issued by the board of health. r T Signed ..... ......... 1C�a�.�..�..................... 6ace 17V Application Approved By .... .. ...� ---- - a ........ .. .... .. .. ............................................ ................. Uace................. Application Disapproved for the following re s s: ........................................................................................................................................ ------------------------------------------------------------------------ ------ -- -.....................----.....................--------------.....-----�------__l__--.... ---............................_...... . "— ^ -gyp' Permit No. .. .... ......................... Issued ---.//'j/� `/') U VC 1................... Dale - - � cp - No... ) -- _ _ T FEs..- ...... ._ THE COMMONWEALT4 OF MASSACHUSETTS ,L BOAR OF HEA DLTH --�_ ale"`4w TOWN OF BAR STABLE l a turonr C r tin xu% #:,Applutf " J�� tA�plr tion is hereby, made for a Per to Constr ct or Repair ( ) an yIndividual Sewage Disposal System,at; •-Location Address77 or Lot No own T Address _ G t �{ Installer Address ! :Type.of Building ; � ` , Size. Lot............................Sq. feet a Dwelling=No. of Bedrooms ...............Expansion Attic ( ) Garbage Grinder' ( )- a, Other—Type.of Building _-. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---- -----•-- ---•- W ' Design Flow..... ..�.. " ...................._g P p P Y T-etal daily flow_______ ............................` gallons. P4 Se tic Tank—Liquid ca acit .. aIoo ss Length...r --e�da Width_______________ Diameter _............ Depth-,._ __..._... P 9 P _ Y b� x' Disposal"Trench No. E�W h:.. ._..Total Length ........... Total:leaching area:__:- ...............sq. ft. 3.: SeSPage-P•trNoIn'7_.t_n�:,Diameter _..__. Depth below inlet :................. Total-leaching area __---.__._--sq. ft. Z ( )' (D'osng tank ( ) t9 Y ` . Pero1 Dio 'I es�Re� u `� ': PA .....................................................' Date_:: .a, pJ ._�::niinuftes; er inch Depth:of Test Pit ...... Depth Depth to ground water________________________ �. i a es r No _ minute-Pe nth Depth 11 of Test Pit .._......-:,... Depth to ground water._;._�__ -____,__.6G Descr p i tion of Soil ..v�.�..r .. T,1 Y v �� '� x .. U W .................. _______ ________ _____. _-____ ____----. ___-_-__ ___-________ _. ---_-_..._-_-...-_-___.. ._. Nature of Repairs or Alterations _,Answer when app applicable - _ : _ „ - _._._._ VQ.r �'- ... - ....................•...... .} =� '�.......................................................................... Agreertlent: ; The undersigned.agrees,:to install.the aforedescribed Individual Sewage Disposal System in accordance,with- the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system^in operation until a.'Certlflcate,of Comp]'ante'has>been:issued by the board of health. _ t ' Signed g c ...�,, ......�. _ ... ......... .. ... Due ... ::. t Application Approved_. ---- ........................................ .�j.:. .�1� J ,, /�,..-� !+e�?�"- _ ✓ Da Il�: Apphcatlon Disapproved r e followsng�e r ... .t,,.+f..A'.............................,......:.......... t .... .... .. ........... . ................... �._ . Permit No ��'/rx�. ..: Issued . -- — .... ............. ............ .1... - Date THE,,COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEALTH TOWfV~.OF BARNSTABLE f1LPr#ifkate of'.(1�onl titan e T IS IS TO CER IFY, That the Individual Sewage Dl'po ai ystem constructed (�_� ) or Repaired (�----- 1 by ..:. . . .. .....--.�--�. �-4 .... .... ........................ ........ ................. Installe�at .-- C c, ..... ................................... - .. .................... - has been inlled n°accordance with,the provisions of TITLE'S, of The Sta E ronmental,C ���� c ibed in the THEdSSUANM OF TH' ISrCE TIFICATE SHALL NOT BE'COONST U .......'AS. dated .: 11..;1'.. J�Disposa ruction Permit.,No A�GU TE THAT THE . SYSTEM WI L'FUNCTI N S ATISFACTORY f DATE.... --- ... Inspector ........... THE;COMMONWEALTH OF MASSACHUSETTS .BOARD` OF HEALTH TOWN ,PF BARN STAB.LE No.,i.. .... ..,/' FEE........................ r T. 'Perm-_ 'is hereby granted............:..Cjl ,� ..:1. a o... :: .x <`�.,........._.._............ to Construct ( ) or'`Repair ((,tea Individual Sev�age Di oral System - ,.... \. street VU GJ ,. =as shown on the.a application for:Dis osal Works Construction, r t No: .:..� d:�. ___'--__-T..--:ti 20 PP. P �^ Board3of;'Heal h DATE.. ...................................... ................................ FORM 36508 HOBBS&WARREN:INc.•PUBLISHERS - ' I Vi � 7 ti h • w i 'i , � r4 t eb f • f o I f 4 � LA