Loading...
HomeMy WebLinkAbout0140 ARROWHEAD DRIVE - Health Arrowhead br Y� • ��27 -. 54' �� . Hyannis ti o ' • n . u ;p .. . � ate. �. - - " w _ .. v _ _ [ '- •- ' P -TOWN OF BARNSTA-BLE L&ATION "� �- ow ° IQA-` - SEWAGE # VILAGE ASSESSOR'S MAP & LOT O'ISI INSTALLER'S NAME&PHONE NO. ° 1-7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS B� WNER e, �-� � a tea- ►z Gt>c�c� PERMITDATE: COMPLIANCE DATE: z r Separation Distance Between the: uMaximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) — Feet Furnished by ~ LOCATIONS LEACH a _ O PIT A. g 1 10 ft 25 ft 2 36.5 ft 43.5 ft SEPTIC TANK • I B EXISTING DWELLING # 140 /No ARROWHEAD DRIVE NOT TO SCALE J' V t TOWN OF B la FABLE 1 LOCKnON, I 0 (f o LJ A • �� SEWAGE vnLreac>✓ a A,SSFSSOWS MAP Sc LOT_____ . ]NSTAl,LFIR'S D1ANE&i'HOME1 NO. i,E.ACiJ]SiG•P/!,CILITX: (Qy (su'.e) l000 No..OF BSDRO BUILT°F.R OR © IrTB tR, S�epiva idu IDistlnat�G 8cslv��eta t��a: Few MAximum��cljustrtl Gtput%�fw�llecTsblela tlic}3cidomoMea;h41 Facility ----w- Pclvalc: 'JVat4► 5uiijaiy 1�1u914i.d t cac hit g P4ciUty ( f WIY Wells exist a r36 ax►situ ac within.200.feet of lenctiirc9 Cgcility) uge cy�''UV.WQ tiu d uny methmd.s exist e' lvidlill 300 feat of leaebing.facility). �~ b � . La A n r, b � ARNSTABL, VIt LAGS v� SSSESSOR'S 1VIAP NSTP►LLEYZ`S NAIIt �c Pt[DIdE/N� C W,CpPACXTY L ACIIrNG:1 AC>I :ity } NO dFSEDFe00iVii$ r DUILDEI(aR C9VJl F F RIl i(T1JA'I('L �C.OWDbC..MCi✓.1D14'lI'Iv Soprhiatxon�9istanoa Betvieea klaa k�cet Mnxutnum Ad�usted:GiaunJwxter'th61e to t6c Battatn of Ixachin�Fsu iUty Pi1va$e'UV'pt�:e Su E� ilJclu��d Y.euai�ing 1?amity (Bfany�rr,Ils exist P17 9 � k�moe �a s9tG or within a0t)feat o�lencti►ug faG�Ilty) ' Ec1(,t�ofi�►I-t 'd and 1,eaedtln�il:�c�llty t a��y wetlaacls east lee llurnl3bad�Y . - �� w � � 0 alb- i5�f 7 , Commonwealth of Massachusetts lF Lz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 1 . 140 Arrowhead Dr Property Address Robert Ward , Owner Owner's Name information is �. required for every Hyannis ' ',. MA 02601 11-23-16 ' page. City/Town - State Zip Code Date of Inspection ` .. _ C0 Inspection results must be submitted on this form. Inspection forms may not be altered in art way. Please see completeness checklist at the end of the form. . - .i t.. A. General Information . /0? 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification • _ Y . 1. .� ,., +: 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 ,r fsewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title*5 (310 CMR 15.000):The system: - + ' N ®, Passes, - ❑ Conditionally Passes [],,Fails ' + ❑. Needs Furthe aluation y the Local Approving Authority 11-23-16 . Inspector's Signature Date The system inspector shall submit a copy of this-inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner ti 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 r r F-, '. at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i t5ins-3113 ':, t:R! �+" % �' s * r;,. a ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of17, o fta-� Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address M Robert Ward Owner,. Owner's Name information is Hyannis MA 02601 11-23-16 required for every page. City/Town State Zip Code Date of Inspection +{ B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - h7 Title 5 Official Inspection . drm r ' Subsurface Sewage Disposal System Form,-Not for,Voluntary Assessments ' r 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is Hyannis ' �'- MA 02601 11-23-16 required for every —y ' page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired: B) System Conditionally Passes (cont.): r ❑ Observation of sewage backup,or break out'or high static water level in the distribution box due to broken or obstructed pipe(§)'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 f� ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y '❑ N ❑ ND (Explain below): �n its j ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C)--Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if, the system is failing to protect public health, safety or the environment. 43`,art=x.jfi'. ` •"'s 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,- j,r't 'safety and the'environment:' 'v s 'rr " . tlrrt1�17"l;'� ! n3 Jtt.,,. Ces r n. i�et. , ,� ❑ spool or privy is within 50 fe of a surface water ❑ Cesspool or privy`is within 50 feet 'of a bordering vegetated wetland or'a salt marsh °. t5ins•'3h 3 t r �:r: �.A .j: ". i .,a , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17) Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments H' 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow [sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts r Vill Title 5 Official. Inspection Form ' '�• Subsurface Sewage Disposal System Form Not for Voluntary Assessments .•-• ��• ,.°° 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis ."'_� i' ' ♦ MA 02601 11-23-16 page. Cityrrown _ *, State Zip Code Date of Inspection B. Certification (cont.) W'a Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: • An portion of the SAS cess ool or privy is below high round water elevation. •'❑ " � Y P r P p Y 9 9 Any portion_of cesspool or privy is within 100 feet of a surface water supply or ` ❑ ® qst tributary to a'surface water supply. i •V ., ❑ ® , ♦ .Any portion of a cesspool or privy is within a Zone 1 of a public well. ® ' Any portion of a cesspool or privy iswithin 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 r ; ,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.] 1 The system is a cesspool serving a facility with a design flow of 2000gpd- 101,0006pd. ';' �; •r'.�,. 4 • rZ. F � '" � t'ram.. . - , ,,,The system fails._I have determined that one or more of the above failure t , ❑ ' ` ' ®`" 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. f 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. , ,t 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 ti the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑` ❑` Area—�IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question'in Section E the system is considered a significant threat, ', • or answered "yes" in Section D above the large system has failed. The owner or operator of any large. system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate , regional office of the Department. . t5ins•3/13 ,'� "" Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17' Commonwealth of Massachusetts Ia=� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection i C. Checklist i Check if the following have been done. You must indicate "yes" or"no" as to each of the following: i Yes No ® ❑ Pumping information-ryas provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 ;for example: 110 gpd x#of bedrooms): 220 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form zt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �•;¢.,% 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis. MA 02601 11-23-16 t ' page. City/Town State Zip Code Date of Inspection D. System Information �. Description: Number of current residents: 3 Does residence have a garbage grinder?�'l ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection • ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? , . r ❑ Yes ® No Last date of occupancy: 11-2016 Date Commercial/Industrial Flow Conditions: • Type of Establishment: Design flow (based on 310 C M R 15.203): Gallons per day(gpd) f '.;.Basis of design flow (seats/persons/sq.ft.; etc.):. Grease trap present? 6 1 ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ INo Non-sanitary waste discharged to the Title 5 system?. ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Owner--pumped within last 4 yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology..Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts ` z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��_,f,✓ 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Approximate age of all components, date installed (if known) and source bf information: 1975 Were sewage odors detected when arriving at the site? .❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: I 12"feet Material of construction: ❑ cast iron E 40 PVC `❑ other(explain): Distance from private water supply well or suction line: • feet ' Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 6".feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate`of Compliance? (attach a copy of certificate)' ❑ Yes ❑ No 9 Dimensions: 1000 gal Sludge depth: 12" t5ins-3/13 t R Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page g'of 17 Commonwealth of Massachusetts h+ Title 5 Official Inspection Form : I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. I . i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts t . a=, Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis , . MA 02601 11-23-16' page._ City/Town a _ State Zip Code Date of Inspection D. System Information (cont.) � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity:' gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form r i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form 1I Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ; f Type: - ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:. ❑ innovative/alternative system Type/name of technology: 4. ►. • Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good working order and holding water at 24" below inlet invert with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ihs 3/13. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 f..I;, Commonwealth of Massachusetts Title 5 Official Inspection Form �10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 v Commonwealth of Massachusetts hi f Title 5 Official Inspection Form - , I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is Hyannis MA 02601 11-23-16 required for every 4 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 40C• G :r 3 —Y-3 . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17, • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 16' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 16'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address j Robert Ward Owner Owner's Name information is required.for every Hyannis MA 02601 11-23-16 page. City/Town 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 ' .A t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist,at the end of the form. t ~A. General Information ± ! 1. Inspector: I Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-8-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only.describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Tins•3/13 Title 5 Official Inspect n r Subsurface Sewage Disposal System•Page 1 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank'(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr , Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) - , ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) 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: 4 ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection i B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. I Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-3/13 Tide 5 Official Inspecdon Form:Subsurface Sewage Disposal System-Page 4 of 17 X, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® . Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 at 17 j Commonwealth of Massachusetts u Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): , Grease,trap.present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No k . Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped within last 2yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 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: 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: . 12"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private.water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Err Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 12" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Dr 'Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 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 N/A 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.): i y x Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No t Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is , required for every Hyannis MA 02601 10-8-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: t ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and holding water at 36" below inlet invert with no other visible stain lines. I Cesspools (cesspool must be pumped as part of inspection) (Iodate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids,layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No p t5ins-3113 +, + Title 5Offiicial Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is Hyannis MA 02601 10-8-14 required for every H y • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 . 10-8-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately UO A_& ,0 az o t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 16' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked', date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than16'. 'Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 140 Arrowhead Dr Property Address Robert Ward Owner Owner's Name information is required for every Hyannis MA 02601 10-8-14 page. City/Town 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 I t5ins•31113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form ,Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane DaSilva- Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information - When filling out ��Ja forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name VQ 43 Triangle Circle Company Address Sandwich MA 02563 - Q 7FQ'" City/Town State Zip Code 508 364-0894 Pending 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: k9 %7 ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority .713 S October 27, 2006 � r- 3�' Inspector's Signature Date rQ The system inspector shall submit a copy of this inspection report to the Approvin Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a s ared 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. Inspectors Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination, t5-2486.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 140 Arrowhead Drive Property Address Christiane Da Silva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water 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. t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or,"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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: ❑ E 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. t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑, the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis annis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? SAS also inspected ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 171 gpd g ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5.2486.doc•08/06 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent 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, di6t�13140Rbex, soil absorption system f ❑ Single cesspool ❑ Overflow cesspool ❑ Privy _ ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ` Approximate age of all components, date installed (if known) and source of information: Age: 29+years. Certificate of Compliance issued 3122176(Board of Health permit# 76-457) Were sewage odors detected when arriving at the site? ❑ Yes ® No ti. . f, r t5.2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 0.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: • 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: . 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Probe to top of tank tS-2486.doc•08/06 + + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. CityfTown 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.): Pumping not required at this time but maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane Da Silva Owner Owner's Name ' information is required for Hyannis MA 02601 October 27, 2006 every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): + ` Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No , . t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to contain 6 inches of effluent in a 1000 gallon precast leaching pit. t5-2486.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form ` s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. j- F j F LEACH LOCATIONS • PIT A B 1 10 ft 25 ft 2 36.5 ft 43.5 ft 4 SEPTIC a TANK e e A. EXISTING P DWELLING . # 140 w 'S Z r K LU n _ 3 fF ti ARROWHEAD DRIVE NOT To SCALE S t5-2486.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 140 Arrowhead Drive Property Address Christiane DaSilva Owner Owner's Name information is required for Hyannis MA 02601 October 27, 2006 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 25feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: GIS Department records ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: I You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 25 feet above groundwater table. t5-2486.doc•08106 V Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r Town of Barnstable Department of Health,Safety and Environmental Services BAPDWABL& HAM Public Health Division 1°rEo 39. 200 Main St.Hyannis,MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health January 29, 2004 Hyannis Skilled Care Center Attn: Bradford H. Stephens 89 Lewis Bay Road Hyannis, MA 02601 RE: 140 Arrowhead Drive re-occupancy requirements The Town of Barnstable Health Division would like to see the following work done to have the property owned by you located at 140 Arrowhead Drive,Hyannis re-occupied. 1. Removal of all rubbish. This includes all waste matter at the property, especially the large accumulation of cardboard in the basement. 2. The oven cleaned out, and operating properly. The oven should never be used for storage, as it causes a fire hazard. 3. The bathrooms and kitchen are cleaned and sanitized. 4. Means of egress made clear. Should you have any questions or concerns, please contact Health Inspector David W. Stanton, RS. Prior to re-occupying the dwelling, please contact Health Inspector.David W. Stanton,RS for a re-inspection after the above listed corrections are made. If possible, you may want to rent a storage building to place your excess possessions where they would not create a fire hazard or a harborage area for insects and/or rodents. c � avid W. Stanton,RS Health Inspector Town of Barnstable QJhealth/order letters/housing violadons/140 Arrowhead cleanup letter.doc �V �6D5,0 ` �a 9 �t� Town of Barnstable ei� k J Department of Health,Safety and Environmental Services I 1 4 0y '.�l L) •'a '"�` . Public Health Division P i63p `0� �iOtE MAS 200 Main St.Hyannis,MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health January 14, 2004 Bradford H. Stephens 140 Arrowhead Drive Hyannis,MA 02601 EMERGENCY CONDEMNATION AND ORDER TO VACATE Finding of Unfitness for Human Habitation and Determination of Immediate Danger The property owned by you located at 140 Arrowhead Drive, Hyannis, was inspected on January 14`t' 2004 by David Stanton, RS,Health Inspector for the Town of Barnstable, after receiving a call from Hyannis Fire and Rescue. Based on the results of that inspection, the Barnstable Health Department finds that the dwelling is unfit for human habitation. Pursuant to M.G.L c. 127B and 105 CMR 410.831 (D), the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. The following violations of 105 CMR 410.00,State Sanitary Code II: Minimum Standards Of Fitness For Human Habitation were observed: 105 CMR 410 750• Conditions Deemed to Endanger or Impair Health or Safety (I) "Failure to comply with any provisions of 105 CMR 410.600,410.601,or 410.602 j which results in any accumulation of garbage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents,insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. There was a large accumulation of garbage, rubbish, filth and other causes of sickness present at the location, including human feces. Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated,they may be forcibly removed by the local Board of Health(M.G.L.c. 127B),or by local police authorities at request of the Board of Health. Q:/health/order letters/housing violations/140 Arrowhead.doc f ` Furthermore, anyone who fails to comply with any order of the Board of Health may be subject to fines of not more than$500. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this dwelling may no a occupied without the written approval of the Board of Health. Note: This is an important legal doc ment. It may affect your rights. Signed Thomas A. McKean Director of Public Health CC: Hyannis Fire Department Barnstable Police Department TO-B. Building Department Cape Cod Hospital. I I • Ili Q:/health/order lettersthousing violations/140 Arrowhead.doc Health Complaints 16-Jan-04 Time: 12:10:00 PM Date: 1/14/2004 Complaint Number: 17231 Referred To: DAVID STANTON Taken By: DAVID STANTON Complaint*Type: CHAPTER II HOUSING Article X Detail: Business Name: Number: 140 Street: ARROWHEAD Village: HYANNIS Assessors Map_Parcel: