HomeMy WebLinkAbout0009 ARROWHEAD DRIVE - Health 9 ARROWHEAD DR., HYANNIS
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Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
v Property Address h
Paulo Cropalaeo
Owner Owner's
Name ,=
information is H annis Ma 02601 4-24-19 �
required for every y ,,
page. City/Town State Zip Code Date of Inspection �r'I
Inspection results must be submitted on this form. Inspection forms may.not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
Co Route
130
45 Company Address
Sandwich Ma 02563
City/Town State Zip Code
r�nv (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey � •^w-^� �• 4-24-19
•'�ma.a.0 onxz day
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
.of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes.conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
■❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owners Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or breakout 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):
I
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.726/2018, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ a Backup o-sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ El Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/M/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ a Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 0 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ the system.is within 400 feet of a surface drinking water supply
• I
❑ ❑ 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
l5insp.doc•rev.MM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5.the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
❑ 0 Has the system received normal flows in the previous two week period?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
[E] ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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?
❑ 0 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:
0 ❑ Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owners Name
information is required for every -Hyannis annis Ma 02601 4-24-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
367/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage(gpd)): See below
Detail:
2018- 86,020gallons 2017- 65,824gallons
Sump pump?. ❑ Yes M No
. -- -Last date.of occupancy: 4-15-19Date
t5insp.doc,-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
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_ A.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
w
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ 'Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped 1 year ago
Was system pumped as part of the inspection? ❑ Yes ❑f1 No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
I
t5insp.doc-rev.M2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
�- ,z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
6-26-06
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
316"
Depth below grade: feet
Material of construction:
❑ cast iron X 40 PVC El other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L
9 Arrowhead Drive
v
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2r6rr
Depth below grade: feet
Material of construction:
0 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: 1500gallons '
. 6Dr
Sludge depth:
3019
Distance from top of sludge to bottom of outlet tee or baffle
On
Scum thickness
Distance from top of scum to top of outlet tee or baffle NS
NS
Distance from bottom of scum to.bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc-rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal [-].fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:.
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
l
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No -
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
i
9. Distribution Box(if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ 'leaching pits number:
❑ leaching chambers number:
❑ Teaching galleries number:
(6)Hi Cap infiltrators
0 leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.726/2018 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
-sue -
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
F
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching was dry when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I '
i
i
j
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
i
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.'7262018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
j 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:
❑E hand-sketch in the area below
❑ drawing attached separately
�y /�y 1N+N ve bANNJldel�
LOC nC l 4QS
VILLAGE _ ASSES50R`:S MAP C,LOT;L Y?1(2—
INSTALLER'S NAPE G PHONE NO.
SEPTIC TANK CAPACITY_/G}j ___
LEACHING PACILITYdtype) /G>U "I_Iai.41,
NO.OF BEDROOMS ✓ PIUVATE WELL OR UBLIC ATER
BUILDER OR OWNER aA", r�&
DATE PERMIT ISSUED-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED:
I
r v 4
t
105 W•t1 AiA caw
t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑■ Check Slope
■❑ Surface water
■❑ Check cellar
Al Shallow wells
No GW @ 120"
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
6-26-06
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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.-
t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18. '
.w s
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
`i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrowhead Drive
Property Address
Paulo Cropalaeo
Owner Owner's Name
information is Hyannis Ma 02601 4-24-19
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
�■ A. Inspector Information: Complete all fields in this section.
0■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
■❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
I
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t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
i
Oct 22 1410:46p p.18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is
required for every Hyannis MA 02601 10-22-14
page. Citylrown 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.
frnp When
fillingg out A. General Information
out forms ``��pUunl4Huiq
on the computer, \�01 ZN OFlifq
use only the tab 1 Inspector. �.°�� ='' `�s9�;'-��
key to move your O�?:' yG
cursor-do not James D Sears ; JAMES :LP
use key./
Name of Inspector
f CapewideEnterprises,LLC
�� � � n o •
Company Name
153 Commercial Street °''�,F S IN SPA;'`
Company Address
» Mashpee MA 02649
City/Town State Zip Code
508A77-8877 S1623
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 Further Evaluation by the Local'Approving Authority
10-22-14
spector'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.
t5ins•3113 I
T1U0 5 Olfidel lrspedi Subsud.Sewage Disposal System•Page 1 o1 17
Oct 22 1410:46p p,19
Commonwealth of Massachusetts
luTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
-
Property Address
Robert Johnston
Owner Owner's Name
require for
is Hyannis MA 02601 10-22-14
required for every
page. citylrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 16.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pass System.The system is a 1500 Gal.Tank D.Box and six infiltrators.
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):
Grins•3113 Title 5 Olfiaal h spedon Form:Subsurfeae Sewage Disposal System•Page 2 of 17
Oct 22 1410:46p p.20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
inforrnation Is
required for every Hyannis MA 02601 10-22-14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarrns are repaired.
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine W
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
65ins-3113 Title 5 orndal hapec6on Form:Subsiarece Sevin a Di 1
A SDosal System•Pege 3 oW
Oct 22 1410:47p p.21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information required for every Hyannis MA 02601 10-22-14
-
page. c4frowrt 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 Zane 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
dogged 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 N is less than 6" below invert or available volume is less
than'/2 day flow 4 FA�°/1/.vim
t5ins 3/13 -nde 5 Official Inspection Fmm:Subsuface S&mVe Disposal System•Page 4 of 17
Oct 23 14 08:03a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is required for every Hyannis MA 02601 10-22-14
page. Cityrrown State Zlp 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 6 Official lnspecUon Form.Subsurface Sewage Disposed System•Page 5 or 17
Oct 2314 08:04a p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information 1s required for every Hyannis MA 02601 10-22-14
page. Cityrrown 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)
0 ❑ 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?
❑ 0 Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3M3 Title 5 Offdal tnspecUon Fomc Subwdace Sewage Disposal System•Pop 6 of 17
Oct 23 14 08:04a p.4
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
Information is
required for every Hyannis MA 02601 10-22-14
page, Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.Tank D Box and six infiltrators.
Number of current residents: 0
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 ears usage 2012-39,000Gais
g ( y g (gpd))' 2013-56,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Commereialllndustrial Flow Conditions: Date
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatstpersonslsq.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:
t - -
t5ins-3113 . Tit! 5 Offidaf Msped ion Fomc Subsudace Sewage Disposal System-Pape 7 of 17
Oct 2314 08:04a p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information
required for every Hyannis MA 02601 10-22-14
Paige- CitylTown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Data
Other(describe below):
General Information
Pumping Records:
NA
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records,if any)
❑ Innovative/Altemative 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 VA system by system operator under contract
t [❑ Tight tank.Attach a copy of the DEP approval.
Other(describe):
mn•Sits rae s oftier b1spoction Fomt Subsurface Sewage Disposal System•Page 8 of 17
ti
. 4 .
Oct 23 14 08:05a p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information
required for every Hyannis MA 02601 10-22-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information:
2006 Permit # 2006- 296
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron [D 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting,evidence of leakage,etc.):
Pipein is 4" PVC SCH 40.
Septic Tank(locate on site plan):
2'
Depth below grade: teat
Material of construction:
IR concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain).
If tank is metal, list age: year
Is age confirmed by a Certificate of Compliance?(attach a copy of certficate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-10
2"
.-Sludge depth:
t5in3-3n3 Title 5 Or6cal Inspection Fomt SL&stufaca Sewage Disposal system•Page 9 oP 17
Oct 23 14 08:05a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner owner's Name
information
required for every Hyannis MA 02601 10-22-14
—
page. cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (conk)
Distance from top of sludge to bottom of outlet tee or baffle
28"
11
Scum thickness 0
n
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape
_Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level.Tank and outlet cover at 2'below grade whrilet cover 8". In and outlet
tee's. No sign of leakage or over loading.
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
Mns•3113 ^' ` �. '`s r,, Title 5 OfWal Inspection Form:Subwrleoe Sewage Deposal System-Page 10 of 17
Oct 23 14 08:05a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Addrm
Robert Johnston
Owner Owner's Name
information is
required for every Hyannis MA 02601 10-22-14
page. Citylrown 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
151ns-3113 rift 5 Official InspeglDn Form:Subsurlaoe Sewage Disposal System•Page 11 of 17
Oct 23 14 08:06a p,9
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is
required for every Hyannis MA 02601 10-22-14
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is WxIT-42" below,grade w/cover at 26". Box is clean and solid,wlone line out No
sign of over loading or solid cant'over.
PumpChamber locate on site plan):
( P )
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:
15ins-3113 Title 5 Official bispattion Farm:Subsurraoe Sewage Disposal System•Page 12 of 17
Oct 2314 08:06a p.10
Commonwealth of Massachusetts
Title 5 official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is
required for every Hyannis MA 02601 10-22-14
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number-
leaching chambers number:
6
❑ leaching galleries number.-
El leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovativetaltemafive system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two roves of three each row. High cap H-20 infiltrators 8'x25'x10"_ CK D Box and
camera out both Iines:Chambers are clean and dry.
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
Indicabonr of groundwater inflow ❑ Yes ❑ No
(Sins•3113 Me 5 Orficid rnspeclion Form:Subsurface Sewage Disposal System•Pape 13 of 17
I` Oct 23 14 08:06a p.11.
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is y required for every Hyannis MA 02601 10-22-14
-
page. CityRown State Zip Code Date of inspection
D. System Information (cont.)
Comments(note condkion of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t5ins•3M3
r _ Title SOfidal Inspection Form:Subsurface Sewdpa Disposal System•PeBe to of t 7
Oct 23 14 08:07a p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is Hyannis
required for everyMA 02601 10-22-14
page. Cityfrown. . 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
13
—J :z / �• i�
A
I v5?fc/1am .-b ECK
P,,nt 1-s
DER r
f3 y -
3 f o 3_
3 ❑
3 - ° Tdb 5 Of ial tnspection Form SLArA0aoe Scwega Disposal System•Page 15 or 17
Oct 23 14 08:07a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Name
information is required for every Hyannis MA 02601 10-22-14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 0
N 10,+
Estimated depth torhigh ground water: teat
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: 6-2-06
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:
T.H.on plan 6-2-06 no G.W. at 10'+_ Bottom of leaching at 5'below grade. Bottom of leaching at 5'
above T.H. Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
[Sims•3113 Tide S Official hrepectbn Form:Subwrfaw Sewapa Oisposat Systain-Pop 16 of 17
Oct 23 14 08:07a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Arrow Head Drive
Property Address
Robert Johnston
Owner Owner's Fume
information is required for every Hyannis MA 02601 10-22-14
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
t
y
6ins•3r13 •.�1 'F Title 5 Ofridal kmpacfon Fam:Subsurface Sewage Disposal system•Page 1T of 17
Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts -( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials-no blanks)
Storage Information - location of storage, how long is storage for?
—]`�—If none, note that.
Disposal Information -where and who? If none, note that.
1 Applicant Signature -understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
plain it
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be Jeft to explain what you discussed with them.
YOU WISH TO OPEN A BUSINESS?
For Your Information:, Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Cleric's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
�v DATE: s L�— l� Fill in lease:
f,a7:yrl.YJ:P,i P r Ria`?li:flr, i
APPLICANT'S YOUR NAME/S: �i4:UL�
�, BUSINESS YOUR HOME ADDRESS:
INTERN
2-80
TELEPHONE # Home Telephone Number C5-"F—86a"6'��
'` r?'bRluvv's4�? ffli' ff'/ 00 -CO
AAL
NAME OF CORPORATION:
NAME OF NEW BUSINESS #Y TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? K YES NO _
ADDRESS OF BUSINESS _ MAP/PARCEL NUMBER o2 T I (� (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you-may need. You MUST GO TO 200 Main St. — Icorner of Yarmouth
Rd. & Main Street) to malce sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING CO ISSI0 R'S OFFICE ST COMPLY WITH HOME OCCUPATION
This individ al ha' n iFi o n nit re uirements that pertain to this type of busirs .
RULES AND REGULATIONS. FAILURE TO
Au horiz i t ** COMPLY MAY RESULT IN FINES.
MMENTSr4_,�nn
,
k)6, i
2. BOARD OF 4ALT4
This individual has-been infor d of the rmit rem efnents that pertain to this type of business.
Aut orized Si ture**
COMMENTS: AMM COMMIX MM-Al�
AZARDO is MATERIALS AWIXATI 'S
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This:individual has been informed of the lidensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Date•,(p
TOWN OF BARNSTABLE
'TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: M WWM?Y �&
BUSINESS LOCATION: _9 MtPW prr�� Pz- INVENTORY
MAILING ADDRESS: . • Lao k I TOTAL AMOUNT:
TELEPHONE NUMBER: 51?' Z$O
CONTACT PERSON: f�vjo
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: -R �ry i 1`N &-
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: All Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
S7�b� Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
e /i (including chloroform, formaldehyde,
Paint&varnish removers, deglossers !i1'L hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS A plicant's Signature Staff's Initials
t TOWN OF BARNSTABLE L6- IOIv A« �,m J SEWAGE# o Mb- 29
VILLAGE �-��C4AN LS ASSESSOR'S M—AP&PARCEL
INSTALLERS NAME&PHONE NO. �GV k�cY,�—y �� 5 JciC� C6 6y
SEPTIC TANK CAPACITY lS�U . t-GC(-
LEACHING FACILITY: (type) (o-5 (size)
NO.OF BEDROOMS
OWNER (;erC-t-3%
'�r.. PERMIT DATE;d(- C1 �d�"" " COMPLIANC_E DATE: '
Separation Distance Between the: '
Maximum Adjusted Groundwater,Table to the Bottom of Leaching Facility Feet
Private Water.Supply We11-'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 leaching facility) NA Feet
FURNISHED BY
�G �b
D
a
O � �
a
e
5o
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v
- ....,"„-r =ry...,.-T..-atl-'�'.�..�.:r-.ram �-.--• . � -
No. (� Fee 0 O
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for Migozal �bpgtem Cow6truction Verm tt
Application for a Permit to Construct( ) Repair(C/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 r l,r Owner's Name
,an,d Tel.No.
a n ^ GCfG'"V 0
Assessor's Map/Parcel 'I
r
I taller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
5A 'Le-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures �l `
Design Flow(min.required) jj�✓ gpd Design flow provided JT 7 gpd
Plan Date Number of sheets Revision Date
Title Size of Septic Tank / o Type of S.A.S. ',LA
Description of Soil 1& Q�P,N/ss its u�c�
Nature of Repairs or Alterations(Answer when applicable) 1t fQ 4_%,
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 /°
Signe Date U�/,j c6
Application Approved by Date
Application•Disapproved by: Date
for the following reasons
Permit No. �� (a Date Issued C71—
•is¢`r �y,.S,::r'...t.� ti::....- �:``.,�, >.,.#.:a^�'i",.w,..�...-.:.�`. ._^r^- �,!�i....,,�.;;-•,li:�. .n,w.`:,...,.. _ .- t� „,r:r�.rv-
Y
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
C HEALTH DIVISION - TOWN Of BARN"STABLE;;MASSACHUSETTS Yes
ZIppYicatiph for �Bigoq;al gppgtem Con5truction4Verrnit
{..
Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
1
Location Address or Lot No. 1 r- !� l{ Owner's Na Address,and Tel.No.
c�d V. r Gcrc� ves
'�•. Assessor's Map/Parcel `'�`�@ Ve•- 0 &or,->�
• •r c..0
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
IF
Type of Building: ,
Dwelling No.of Bedrooms — Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures �r
Design Flow(min.required) 7,?U gpd Design flow provided �Jh 7 gpd
Plan Date Number of sheets Revision Date
Title _ l y,
Size of Septic Tank /� 0 Type of S.A.S. �o .�-/� �'1 �.�CJ1�s
Description of Soil - A PS fnne .2• A ry yJ
Nature of Repairs or Alterations(Answer when applicable)
r
Date last inspected: j
Agreement:
The undersigned agrees46 ensure the construction and maintenance of the afore described on-site sewage'disposal system in r
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 b this Board of e e�
Signe Date
t= Application Approved by Date O
ApplicatiomDisapproved by: Date
for the following reasons
Permit No DR Date Issued j
-------=—=---=-----------------=-----=—'—=---
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certiftcate of Compliance
THIS IS TO CERTIFY,that 1the On-site Sewage Disposal System Constructed ( ) Repaired V) Upgraded ( )
Abandoned( )by Lr�-(� Got
at i-Lhas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _006 6 dated
Installer Cd � �. Designer
.; #bedrooms v :R Approved design flow gpd
The issuance of this permit sh 11 fiott be c/o-nstrued as a guarantee that the system will function a e i ed.
Date <�/. // tP Inspector \;
r
y -
---No. ————————————————————-----=------ Fee =—:_--_—
-' O(o—o D�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
ltgogal i§pgtem Congtructton Vermtt
-Permission is hereby granted to Construct ( ) Rep air (VI) Upgrade ( ) Abandon ( )
System located at A a o w V�tG.IJ t,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
' Provided: Cons ctiGo,�n ust be completed within three years of the date` of this e t.
Date t/o .��'"I C Approvedb,
own of Barnstable
Regulatory Services
Thomas F.Geiler,DirectorIZIPWABIA
t
Public Healt Division
Thomas McKean,Director
2110 Main Street,Hyannis,MA,02601
4: 508-862 4" `
'. Fax: 508-790 b304
Installer i i Desigger Certification Form
!Amm Sewage Per:n it# v v 6 �z issessor's Map1I'arcel Z-71
:I,-a er: N c--j t+-a_rq•s , p.C- Installer:
C fc
IONS: 'La lvVIE-, &A _ Address:
was issued a permit to install a
c System at� �fu-�wk�►«� ;>.� . r�,r,a,,�;rS based on a design drawn by
(ad d ess)
e:;0 At C-V( '9 S _ dated
"des: paer)
certif i th: : the septic systei n referenced above was installed substantially according to
the design, which may'i nclu(le minor approved changes such as lateral relocation of the
distribution box and/or septic b ak,
_ 1. certif tlhs the septic syste r referenced above was installed with major changes (i.e.
greater than 10' lateral relocati in of the SAS or any vertical relocation off any component
Of the E epti, system)but in a,:c)rdance with State&Local Regulations. Plan revision or
Jhertifiel as- )uilt by designer i o follow,
� 1N OE
1)x�staller's i mature)
.,;
(Designee's S mature) (A ix esa s Stamp Here)
ASE RETUR i TO BARN STE►l, E PUBLIC HEALTH DIVISION. rv.DTIFICATE
�t)MlPLIXIM E WILL NOT I E ISSUED UNTIL BOTHICTHIS FORAM AND AS-
AIR t:RECEIVED B If M''BARNSTABLL+" PUBLIC HE,ALTHf DIV$SI®I�.
31 ,Iks*cr Cei tli alioll Foam Revisod.do:
A .IV i
0, 0'7:25 50 4301846 MCNAMARA DEPOT ST PAGE 03/06
CVDEPOT STREET NURSERY
Perennials • Ornamental Grasses
492 Depot Street
N. Harwich, MA 02645
(508)430-7878
fPSOPHILI. Pink Baby (CREEPING) FLOWERING
Pink Fairy FLOWERINGS
IER0CAI LIS Black Eyed Susan
Bonanza
Stella D'Oro FLOWERING
Frans Hal
Fulva FLOWERING
` Hyperion
' Happy Retums
Ice Carnival
-�TEROFAP; US Blue Knoll
-,UCHEI:A Palme Purple BEAUTIFUL FOLIAGE
J,U?'UNY1A Chameleon
NIPHOF:(A Pfitzers Hybrid
kN[IASTRII [A Herman's Pride
S AgSIA Special Mir
I
XTRIS Kobold
I:IOPE Muscari '
i THRUP/i Morden Pink LIMITED
• 1, ���
}� ).'OSOT:.S Forget-me-not FLOWERING
,,
ENOTH TJ Pal ida White BUD/FLOWERING
Hybrid Yellow BUD/FLOWERING
�'N§TEMOT Husker Red FLOWERING
I
1
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERGOLA TION TEST AND SOU.EVALUATION EXEMPTION FORM
1.
_ ,hereby certify that the engineered plan signed by me
dated O(o ,concerning the property located at
I
.f��ta sue .ram Dom-? , �l Ya►..e�u�'1�.meets sll of the
tWolving criteria:
Q 'wo soil evaluations excavated for detailed examination(no hand angering)and two
percolation tests shall be conducted.
«This failed syi;tem is connected to a residential dwelling only. There are no commercial or
business uses:associated with the dwelling.
�• A he soil is cla-;sifted as CLASS I and the percolation rate is less than or equal.to 5 minutes
I er irich:
re is no`in sense in flow and/or change in use proposed -
�l'here are no A ariances requested or needed.
• I>bottom ol'the proposed leaching facility will be.l"ocated no less than five feet above the
ti C-'inaximum adj•isted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please Complete the following:
A) Top of Cn ound Surface Elevation(using GIS information) _60
13) G.W.Elevation +adjustment for high G.W.
DE FTRENCE B'?TWEEN A and B
SIGNED :_ ` _ DATE:
NOTICE
Bascd upon the al)ove information,a repair permit will be issued for bedrooms
I maximum. No a0ditional bedrooms are authorized in the future without engineered septic system
plans.
q:l�ticlpenexewp.da:
PERENNIAL 12"PATIO POTS 12"PREMIUM PATIO POTS a-
8.50 PER POT $10.00 PER POT
* NOT HARDY BELOW ZONE 6
GRASSES
ASTILBE(FALSE SPIREA) PEPT134 CALAMAGROSTIs Karl Forester(2-6')
PEPT227 Deutschland(White) PEPT072 CHASMANTHIUM Latifolium(34)
PEPT324 Granat(Deep Red) PEPT246 MISCANTHUS Graziella(5-7')
PEPT305 Visions(Lilac)
BUDDLEIA(BUTTERFLY BUSH) 12"PREMIUM PA710 POTS
__ PEPT230 Attraction(Magenta) $25.50 PER POT
SM PEPT086 Lochinch(Lavender)
PEPT231 Royal Red(Magenta) HYDRANGEA
PEPT318 Endless Summer
DIGITALIS(FOXGLOVE►
PEPT094 Foxy(Mix)
1 GALLON GRASS
GAURA $4.50 PER POT
PEPT082 Come's Gold(Gold/White) ' NOT HARDY BELOW ZONE 6
HEMEROCALLIS(DAYLILY) GRASSES
PEPT252 Joan Senior(Whitellime throat) GRAS015 PENNISETUM Rubrum
PEPT021 Stella De Oro(Golden Yellow)
PEPT320 Stella Supreme(Yellow)
PEPT249 Wineberry Candy(Orchid/Purple) CLASSIC PERENNIALS
$4.75 PER POT
HOSTA(PLANTAIN IDLY) MINIMUM ORDER 10 PER VARIETY
__ PEPT050 Blue Angel(Blue, Large) ' NOT HARDY BELOW ZONE 6
__ PEPT102 Frances Williams(Green/Gold)
__ PEPT257 Krossa Regal(Blue Grey, upright) ACHILLF.A(YARROW)
PEPT104 Wide Brim(Green/Cream) PECL002 Apple Blossom�(Pink)
PECL007 Moonshine(Lemon Yellow)
LIUU M(LILY) PECL008 Paprika(Red/Yellow)
PEPT332 Dynamite(Red) PECL009 Red Beauty(Crimson)
PEPT264 Siberia(White)
AJANIA(SILVER AND GOLD)
NEPETA PECL1133 Mimosa Pink
PEPT033 Walker's Low(Blue Purple, 18') ALCEA(HOLLYHOCK)
RUDBECKIA(BLACK-EYED SUSAN) PECLO18 Chater's Double Maroon
PEPT041 Goldstrum(Yellow/Dark Eye) PECL020 Chater's Double Purple
PECL026 Chater's Double Yellow
SEDUM(STONECROP) PECL1335 Happy Lights(Single Mix)
PEPT044 Autumn Joy(Rose) PECL025 Simplex(Single Mix)
PECL1408 Summer Canival Yellow
SOLIDAGO(GOLDENROD) PECL1406 Summer Carnival Rosy Pink
PEPT283 Fireworks(Orange/Red)
ALCHEMILLA
VERONICA(SPEEDWELL) PECL027 mollis Auslese(Yellow)
PEPT287 Royal Candles(Violet Blue) AMSONIA(BLUE STAR FLOWER)
PECL1109 Blue Ice(Dark Blue)
ANEMONE(WINDFLOWER)
PECL031 Honorine Jobert(White,Single)
CaviccWo Gmcnhouses Availability Week of 6.25.06 (978)443-7177 FAX(978)443-5440 Page 5 of 9
y
�,�'��t�t CPC-=.►Z,v.-� oU ®t� 1� ��\2 �4�a� �,Ca�wi�] u�.i # � �t�2.�w
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1� �o�' �G:s� L`� �, ems' �C o���' �C:o��� ` � . C✓c7u�T�
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7
TOWN OF BARNSTABLE
r q
SEWAGE # (0 d I�
VILLAGE 1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. G,(- C 4S , L1 7 7 4
SEPTIC TANK CAPACITY t O O 0 �!ie-L ®O L-�
LEACHING FACIL=: (type) �3 rc'lxx `^ (size) /d I 1
NO. OF BEDROOMS
BUILDER OR OWNER q
PERMIT DATE: r �✓ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 any wetlands exist
within 300 feotof leaching cility) Feet
Furnished by o �����
,ik
Ef ° p
i
i
1�
MSSE�50RSI W KM 7 I
No. Fee
PARCEL.NO: J0_:.
THE COMMONWEALTH OF MASSACH SETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for �Digpool 6pgtem Construction Vermit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
�• 1 �r.rts...0 `��A� � ram`�.�
Installer's Name,Address,and Tel.No. �}r(1 a`3 3 s— Designer's Name,Address and Tel.No.
1 .3 a 9 <o wt A
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title c
Description of Soil
Nature of Repairs or Alterations(Answer w n applicable) c ,. SLj S wh .
e to c,,y+.a t3 e r: V%"%I-L .. Z" '1 D e A.- _14p ca,t .
Date last inspected: yw �•
Agreement: rK 1 A I,a
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 Certifi-
cate of Compliance has been ' s ed b s Board of Health.
Signed. Date
Application Approved by
Application Disapproved for the fo owing reasons
Permit No. Date Issued T� ��
No ' _ I D ,_... ._.� Fee r 40, OD
t• _.
t THE COMMONWEALTH OF MASSACH SETTS
PUB'LtC"HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 4
- A� Application for aie;paai *p.5tem Construction Vermit
Application is hereby made for a Permitto Construct( )or Repair( )an On-site Sewage Disposal System at:
c
Location Address or Lot No. Owner's Name,Address and Tel.No. ,•�
Installer's Name,Address,and Tel.No. 47 -'.18 3 Designer's Name,'Address and Tel.No. '
r\ �.o`^' 11r Z,yJ�r: �-1+-S• L'a-�-\ �-o,�.- �2,.-�...o �.1 c_S . �
r Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Sa..,.aa
t r/ �.
} Nature of R'epairs;or ,Alterations(Answer when applicable) w4 5 fie. n+,e •4- `� Lc h c S s
11 o C:%'_i, �e � K ec�n cam.
�'b w t 4 r u w.► Q! van i " yffCA 54o k.1 a
Date last inspected: _w S+. i ` P e< d'r'±'"4�A p"p Clow L.-
Agreement:
4
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 Certifi-
cate of Compliance has been 's's�i ed b is Board of Health.
Date
Application Approved by -
Application Disapproved for the fo owing reasons
t
Permit No. Date Issued T9�
THE COMMONWEALTH OF MASSACHUSETTS
�f PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(V)on 1
A rew�\e&A Q by Car\ irm— &AL-S . for
as has been constructed in accordanc
j with the provisions of Title 5 and the for Disposal System Construction Permit No. fi dated -r
Use of this system is conditioned on compliance with the provisions set forth below:
No. Fee 4 d •O O
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migw5al *pgtem Construction Vermit
Permission is hereby granted to L r•: c-k- S'
to construct( )repair C)Qan On-site Sewage System located at �p�K• a P _
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
cotm�ply with Title 5 and the following local provisions or special conditions.
11 Alrconstru((cttion must be completed-within two years of the date below.
�( Date: 1 o.r: `( 1 1 b Approved by�, 2
J
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I,Ca, 66 hereby certify that the application for disposal works
construction permit signed by me dated AVvJ -9 concerning the
property located at meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
I
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or.,change in use proposed
• There are no variances requested or needed.
r
SIGNED : ` `
� • � DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
+� E
1
a
548 65], 034
Receipt for
Certified Mail
No Insurance Coverage Provided
IaATE�D�.t�iaifc o not use for International Mail
POSTAL SEiYILE
i (See Reverse)
0) Sent tW
0) r
t Stree No.
A000
P.O.,Sta a d I Code
� Postage A
CV) a
E Certified Fee
LL N Special Delivery Fee
, es ric�,Lre 6v�ty I e�
i
e µrn ecegt'„owuLg
to Whom&Date
Return Recei i
Date,and re
TOTAL Po
&Fees
Postmar to
t.
STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE,
CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front).
' 1 m
1. If you want this receipt postmarked,stick the gummed stub to the right of the return address La
leaving the receipt attached and present the article at a post office service window or hand it to i
your �rural ca ' extra charge). )
2. I you do ot.wa receipt postmarked,stick the gummed stub to the right of the return rn
ad etds a article,dat`e,;�etach and retain the receipt,and mail the article. CY)
31" q,�vanjfa,retwn.receipwrite the certified mail number and your name and address on a
re n eceipt card, oi4i 381�1,land attach it to the front of the article by means of the gummed cc
Ads if space permits.Otherwise{raffix to back of article.Endorse front of article RETURN RECEIPT
R If y UNTED adjacent to the number. 46
CID
4. u.want delivery restricted to the addressee,or to an authorized agent of the addressee, M
endorse RI'STRICTED DELIVERY on the front of the article. 9.
0
5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If LL
return receipt is requested,check the applicable blocks in item 1 of Form 3811. to
a
6. Save this receipt and presont it if you make inquiry. 105603.83-B-0218
J
Town of Barnstable
B
• Department of Health, Safety, and Environmental Services
MASS.B
+ �►ttu � Public Health Division
y A98
039.
Eon" 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean
FAX: 508-775-3344 Director of Public Health
January 23, 1996
R.I. DEPCO
9 Arrowhead Drive
Hyannis, MA 02601
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 9 Arrowhead Drive, Hyannis was inspected
on November 1, 1995 by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Septic system in hydraulic failure
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen
days of receipt of this notice.
. You are also directed to bring the septic system into compliance within thirty (30) days
of receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
�fiomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
[Installer letter] Sl
TO: � (Date)
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE S.
The septic system owned by you located at $ew is
inspected on /�~�""� by e ��9'A� a Massachusetts licensedp
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: ;
You are directed Ito hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
o
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean,R.S.,C.H.O. .
Agent of the Board of Health
Town of Barnstable
.Gaels. Q!�'-J vc-'a,;,'
it
Iks V }
T • -
mmonwealth of Massachusetts. . -
j;M John Grad
-Executive Office of Environmental:Affairs -:
D.E.P. Title V Septic Inspector•
�opartment of P.o. BoX 2�i9 _-
O
iy1A 02536
• :Envir'onmental Protection - Teaticket, _
(650
-.-WHO ain F:weld. - - � }t� � 13
Trudy„Coxe
Seareury,-EOEA
I.Wd:B..Struhs. . . £�
commiWoner _ _ `.. y
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM gar'
— - . - - - PART A _ Qv F.l 1•.
CERTIFICATION N
Property.Address: \ kCA nr� > Address of Owner:
Date of'Inspection: �� � JOHN GRAC.if different)
Name of Inspector: Title I Inspector /
Company Name,.Address and Telephone Number: P.O. Box 2119
Teaticket, MA 02536 MAWN
CERTIFICATION STATEMENT
I certify-that I have persbnally inspected the sewage disposal system at this address and that the information reported—below is true, all"
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: /� /_ZT
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority b4G
`Fails
Inspector's Signature: / Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of io,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 :ne system owner and cope. set,.: tj tiie lJuier, if applicable and the appro.ing aua,orit).
INSPECTION SUMMARY:
Check A, B, C, 00
AJ SYSTEM PASSES:
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.
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 6/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)S66.1049 • Telephone(617)292-'5300
L
Printed on Recycled Paper
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
S.
Owner:. vISC - -
Date of Inspection:
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).
-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 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.
I
_ 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 above:
The design flov,, of system is 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 11 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 8/15/95) 3
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM .
PART B.
CHECKLIST
Property Address:' -
Owner: 1 1 ,
Date of Inspection: _
Check-if the following have been done:
P mping information was requested of the owner, occupant, and Board of Health.
l f—
None of the of this inspection.
system components have been pumped for at least two weeks and the system has been receiving normal flow ryes
during that.period:. Large volumes of water have not been introduced into the system recently or as part
1T'lAs built plans have been obtained and examined. Note if they are not available with N/A.
The'facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
`III system components, excluding the Soil Absorption System, have been located on the site.
</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.
VThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods
,,., ;,,,,, ;i(f m itiPrP�� fro Q\1'nP-', were provided �•'ith information on the proper maintenance of Sub-
The rz„',Surface Disposal System.
4
(revised 8/15/95)
' SUBSURFACE SEWAGE,DfSPOSAI'SYSTEM INSPECTION FORM
_. ;. PART C
SYSTEM'INFORMATION
Property Add ess: - - -
Owner.
Date of Inspection:_ '1 f♦. a� - _ _ - - -
FLOW CONDITIONS
RESIDENTIAL:
Design flow: y` allons -
Number of bedrooms:
Number of current residentsc:-G
_Garbage grinder (yes.or no):
Laundry connected to system (yes or no).A-J,/�, _
Seasonal use-(yes or.no):5D
Water meter readings, if available: _
Last date of occupancy:
COMMERCIAUINDUSTRIAL: 041T
Type of establishment:
Design flow:____gallons/day
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 RE(;:QRDS 4nd sourc of form do
it J
System pumped as part of inspection: (yes or no
If yes, volume pumped eallons
Reason for pumping:
TYPE OF SYSTEM
L-"—Septic tankfdist;mb++ue"-borz%oil absorption 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 of information:
Sewage odors detected when arriving at the site: (yes or no)
5
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
} PART C
- SYSTEM INFORMATION (continued) -
Property Address:
Owner:. __ .
Date of-Insp= Or�Ci --
SEPTIC TANK:_
(locate.on site plan),
Depth below:grade:
Material of construction: _concrete _metal _FRP _other(explain) -
Dimensions: t
Sludge depth:_T�. tt
Distance from'top of sludge to bottom of outlet tee or baffler
Scum thickness: it
Distance from top of scum to top of outlet tee or baffle:
ti
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, concl n f inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert structural
integrity; evidence of leakage, etc.) C,
.S•
-14
J
GREASE TRAP:-1t I
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP _other(explain)
Dimensions:
Scum tnickne».
Distance from top of scum to top of outlet tee or baffle:
(licf2nro from bottom n+ cr-ii•n t^ hotfom Of Ourlcr tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
I
integrity, evidence of leakage, etc.)
(revised 8/.5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
PART C
,SYSTEM INFORMATION (continued) -
Property Addr s: -
_Owner: ` --
Date of Inspection:
TIGHT OR HOLDING TANK1 1`('C - -
(locate on site-pIan) - - -
- Depth below.grade: - -- - � - -
_ Material of.construction: _concrete _metal _ERP other(explain)
Dimensions:
Capacity: gallons
Design.flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:C� A
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if le%,ei and distnbuuur, ryudi, e,.dcr,cE c, so:ld_ ca:r,c,',cf, e\:dence o;leakage into or out of box, etc.)
PUMP CHAMBER: (Yn—
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/IS/95) 7
p
s t" SUBSURFACE-SEWtkgE DISPOSAL SYSTEM INSPECTION FORM - Y
1 PART C
- SYSTEM INFORMATION (continued)
Property Ad ress:'.'.a � {�
Owner: -
Date-of Inspedton:
SOIL ABSORPTION SYSTEM'(SAS) -
(locate-on site plan, if possible; excavation not.required, but may be approximated by non-intrusive methods)
If not determined.to be present, explain:
Type:
leaching pits, number:'
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: i
Comm ts: (note condition of soil, si s of hydraulic failure lev I of p nding on ition of ation,etc.) tom-
CTV
CESSPOOLS:
(locate on site p(an)
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 grog,d.,atc
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:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
(revised 8/15/95) 8
SUBSURFACE SEWAGE:.DISPOSALSYSTEM INSPECTION FORM
PART
(conti ATION
SYSTEM.'IIVFORMnued)
..:
Property Addressr
Owner:. i� O _•-
Date of Inspectio r,
SKETCH OF SEWAGE DISPOSAL SYSTEM: -
include ties to at least two permanent references landmarks-or benchmarks..
locate all wells within 100' .
0
Q
DEPTH TO GROUNDWATER
Depth to groundwater:_&feet `
method of determination or approximation:
9
(revised 8/15/95)
J'OHN. R. GRAC.I �
- D`..E.P.: ..T.fiThE'N SEPTIC INSPECTOR
BOX 11.19.
TEATICKET, MA. _M535 "-
_- 508 '564-6813 _
_ November 4, 1995. -
My findings . for the septic -inspection on 9 Arrow-Head Rd. ,
- Hyannis are as follows : The septic system shows signs of being
- in hydraulic failure and , the foundation of. the addition is on
top of the inlet side 'of the septic tank. Due to the 1978
building code , septic tanks are suppose to be 10 feet away
from: any structural foundation. The danger would be the septic
tank collapsing and sewage pouring into the
foundation.. My recommendation is that the whole septic system
be replaced , and a new system meeting all the new guidelines
be installed .
John P . . Graci
i . .
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM % t 9
PART A ! �
CERTIFICATION
e� 66
Property Address: 9 ARROWHEAD DR. HYANNIS MAP 271 PAR 104 L$ (�i' �ifOVED
Name of Owner H.U.D `
Address of Owner: CIO REALTY EXECUTIVES 1682 RT.132 HYANNIS ATT..JACK r .I U L 2 2 �999
Date of Inspection: 7/13199 �1VNOF8gRjy
ARE
Name of Inspector:(Please Print)JOHN GRACI e1� ALTHDel
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: nla Qv
Mailing Address: n/a y
Telephone Number: nla
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 The Inpection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Ev luafon By the Local Approving Authority performing at the time of the Inspection.My Inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: GA Date:7/14/99
The System Inspector sha submit a copy of this 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 now 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
THE SYSTEM PASSES-TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.THE SUNROOM IS 6"OVER THE
SEPTIC TANK,AND DOES NOT MEET THE 10'SEPARATION FROM THE SEPTIC SYSTEM.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa 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.
nta 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
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
nLa 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 pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
Wa 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
I
I
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.13
Date of Inspection:7/13/99
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 I 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 is equal to or less
than 5 ppm,Method used to determine distance ll(a- (approximation not valid).
3) OTHER
Wa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
D. SYSTEM FAILS:
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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Wa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a 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 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98. Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7113/99
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,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.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13199
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):I
Total DESIGN flow: IU
Number of current residents:It
Garbage grinder(yes or no):MQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no).*-=
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): nta
Sump Pump(yes or no): NO
Last date of occupancy: 2/1199
COMMERCIAL/INDUSTRIAL
Type of establishment: Wa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: nta
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n(a
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Wa
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped nLa_ gallons
Reason for pumping: n&
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: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
NEW LEACH FIELD WAS INSTALLED IN 1996 PERMIT96 129
Sewage odors detected when arriving at the site:(yes or no): MQ
revised 9/2/98 Page 6 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7113/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V 6"
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n1A
Comments: (condition of joints,venting,evidence of leakage,etc.)
Wa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No
n/a
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: E
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:. E
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
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 PUMPIN YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass._ Polyethylene_other(explain)
nla ,
Dimensions: Wa
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle:_n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n&
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
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n1a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n/A
Dimensions: nta
Capacity: n/a gallons
Design flow: WA gallons/day
Alarm present: MQ
Alarm level:jj[a. Alarm in working order:Yes_No_: NQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n&
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
DIa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Wa
Type:
leaching pits,number: nLa
leaching chambers,number: 3-R HAR R
leaching galleries,number: jiLa
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nta
overflow cesspool,number: n1a
Alternative system: nLa
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE SAS IS FUNCTIONING PROPERLY-
CESSPOOLS: _
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: nta
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
DIA
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n1a
Depth of solids: Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,,etc.)
n1a
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes Into house)
n/a
� D
1A
revised 9/2198 Page 10 of 11
v .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ARROWHEAD DR.HYANNIS MAP 271 PAR 104
Owner: H.U.D
Date of Inspection:7/13/99
NRCSReportname: nLa
Soil Type: Wa
Typical depth to groundwater: nLa
USGS Date website visited: nLa
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:.
_ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2198 Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
Pr ape Address
Cfty[To state Z1p Code
. Q ro - 0-0
Owners Name 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.
RT
`Y
. i
nZ
y
rvem;ouvaun'ace sewage Disposal system
Page 15 of 16
ti
ACCESS COVERS MUST BE WITHIN INSPECTION 9' MINIMUM. I NVERT ELEVATIONS DESIGN CR I TER I A : GENERAL NOTES :
6" OF FINISH GRADE PORT 3 ' MAXIMUM COVER
102.04 FIRST 2 ' TO INVERT AT BUILDING: 97. 0 DESIGN FLOW:
BE LEVEL MIN 2" OF PEASTONE INVERT IN SEPTIC TANK: 96.25 3 BEDROOMS AT I10 G. P.D. PER I . THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION
INVERT OUT SEPTIC TANK: 96.0 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4' DIAM PIPE 3/4" - I I/2" DIA. INVERT IN D/ST. BOX: 95.5
97. 0 �� 0 /0' %o DOUBLE WASHED STONE INVERT OUT DIST. BOX: 95. 33 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
96. 25 + BAFFLED 9 5 1 SEPTIC TANK REQUIRED:94. 4 INVERT /N LEACH CHAMBER: 95.23 SET. SEE SITE PLAN.
3 OUTLET 6 HIGH CAPACITY INFILTRATOR BOTTOM OF LEACH CHAMBER: 94•4 330 G.P.D. X 200X - 660 GAL . 3. ALL CONSTRUCTION METHODS AND MATERIALS AND
CHAMBERS W/2. 5'' STONE AROUND ADJUSTED GROUND WATER: N/A SEPTIC TANK PROVIDED: 1500 GAL . MIN.
D-BOX MAINTENANCE OF THE SEPTIC SYSTEM SHALL
1500 GAL 2-8 r x 25 ' 1 x IO'd OBSERVED GROUND WATER: N/A
CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL
SEPTIC TANK 6' CRUSHED STONE OR
BOTTOM OF TEST HOLE *1 : 89. 1 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE
DESIGN PERC RATE l 5 M I N/INCH
PROFILE NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3 ' IN DEPTH SHALL BE CAPABLE OF W1 TH-
STAND ING H-20 WHEEL LOADS.
PROVIDED: 6 HIGH CAPACITY INFILTRATOR
CHAMBERS W/2.5'' STONE AROUND. A-496 S.F 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR
496 S.F. x 0. 74 - 367 GPD APPROVED EQUAL .
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SO I L TEST PIT DA TA & PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL
INDICATES �_ l ND l CA TES BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE
Z PERCOLATION - OBSERVED IS MORE THAN ONE OUTLET.
j j T TEST GROUNDWATER
R O v 7. BEFORE CONSTRUCTION CALL "DIG-SAFE'.
1 TP +I TP *2 1-888-DIG-SAFE AND THE LOCAL WATER DEPT.
0"
HORIZON TEXTURE COLOR 99. 1 0' HOR/ZON TEXTURE COLOR 99. 3 FOR LOCATION OF UNDERGROUND UTILITIES.
L OAMY !O YR ^ LOAMY I O YR
�� 99 SAND 2/2 H 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
-_FENCE ��- \ n SAND 2/2
34.2 p-E s rocKADE 98. 5 B" 98. 6 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
N 78° 84 • - \\ �\ /' 7 �' LOAMY IOYR p LOAMY lOYR OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
i27. - ` \ b SAND 3/6 D SAND 3/6 CONSTRUCTION INSPECTIONS.
96. 6
-------- ` \� ---� / MED-COARSE IOYR C / MED-COARSE IOYR t
SAND AND 5/6 SAND AND 5/6
�- GRA VEL GRA VEL -
52' 48'
EXISTING
SAS
2 p� NO WATER 89. 1 120" NO WA TER 89. 3
Q i500 GALLON
DATE: JUNE 2. 2006
SEPTIC TANK ` W ? Q ^ /
LOT V `t TEST BY- S TEPHEN HAA S
i 6 HIGH CAPACITY 30 r� ?0 3 PERC RA TE- l 2 b41 N/I NCH
OF
L INFILTRATOR CHAMBERS fX S7/N pp /6. 228+ S . F. b �H
�u W'/t.S 1 STONE AROUND it TANK TO BE �. •k p 4 b j�
REMOVED a m �� p A.
O
L
I0
8H FNC o D 80X� --� J J
EL-99 47
TP12
5'OCA40C FFNCE _ _` OqV"e*4
S E T / C S Y S 7-zS- 0 E S
9 4RROWHEAD DR / VE- . M,4P 27 / P,4RCEL 104
/ CB/DH FND SA R /V S 7 A S L E , < H YA /V/V / S ) "A
I 1
PREP,4 RED FOR
LEGEND S C O T T /=- R ,4 /N/ K
I l ■ CB CONCRETE BOUND 27 / P / /VE S TREE T . CE/V TER V / L L E- . MA 02632
R T I O W TER LI NE SC,4 L E / - 20 .JU/VE 26 2006
1
- 1
Locus ; , GAS L l NE A G L E SURVEY I NO 51 1 NC
1 . w OHW- OVER HEAD WIRES
/ a. # LIGHT POST _ 923 Rou t e 6A
< -E- UNDERGROUND ELECTRIC LINE i� � = Y o r mo u t h p o r t MA 02675
-T- UNDERGROUND TELEPHONE LINE /G/ ' I/ 1� � ( 508 362-8 1 ,32
-CTV- UNDERGROUND CABLEVISION LINE 5 0 8 4 3 2-5 3 3 3
+ 40. 4 SPOT ELEVATION
-40-_- EXISTING CONTOUR
n PROPOSED CONTOUR
L O C U S MA 0 /0 20 40 P JOB NO: 06-069 F/EL D:CFW/EEK CAL C: SAH/CFW CHECK CFW DRN: SAH