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HomeMy WebLinkAbout0156 ARROWHEAD DRIVE - Health '15.6 '',whead'Drive �* :Hyannis. P. I � a o TOWN OF BARNSTABLE LOCATION _ /�!L/l e h eu. d - : SEWAGE VILLAGE AIAI c ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.- SEPTIC TANK CAPACITY o Ad b o� LEACHING FACILITY: (type) 441""J (size) _NO.OF BEDROOMS a' 4 ,BLUDER OR OWNER 'PERMITDATE: COMPLIANCE DATE: &9 000 i 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(If any wetlands exist , within 300 feet of leaching facility)` __ Feet . Furnished by r r • d V f � Commonwealth of Massachusetts ado - i5a� • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive �C Property Address Fred Knize Owner Owner's Nam information is H J� annis r Ma 02601 5-16-16 required for every y �.+. page. Cityfrown State Zip Code Date of Inspecti I W • 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. General Information " on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return key. Name of Inspector B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification 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 5-16-16 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ' �o��e� VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 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: System was in working order at time of inspection. Old pit is still hooked up aswell 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. I 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): !Sins!3/13 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced - ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if -+ the system is failing to protect public health, safety or the environment. -1. System will pass.unless Board of Health determines in accordance with 310 CMR .' 15.303(1)(b)that the system is,not functioning in a manner which will protect public health, - _ safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water - ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive Property Address Fred Knize r Owner Owner's Name information is H annis Ma 02601 5-16-16 required for every —Y 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 I . ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in-cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive - Property Address Fred Knize - Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ page. Cityrrown 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 . - w 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 eitheryes" or no to each of the following, in addition to the questions in Section D. Yes No 3i• ❑ ❑ the system is within 400 feet of a surface drinking water supply ` ;: k; ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ; t El 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 r ; 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 1 ' .'system considered a significant threat under Section E or failed under Section D shall upgrade the r; system in accordance with 310 CMR 15.304.The_system owner should contact the appropriate •, _. 4regional office of the Department. +! + !Sins•3113'. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i - Commonwealth of Massachusetts Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive ' Property Address Fred Knize Owner Owner's Name information is required for every �H annis Ma 02601 5-16-16 page. CitylTown 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 r ❑ ® 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 volume_ s 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 breakout? ® ❑ 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] . D. System Information r Residential Flow Conditions: , Number of bedrooms (design): 3 Number of bedrooms (Actual) ' 3. 349 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ' r l5ins-3/13 r _ Title 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 w 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ page. City/Town 'State Zip Code Date of Inspection D. System Information Description: Number of current residents: y 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 d See below 9 ( Y 9 (gp ))� Detail: 2014- 1,500gallons 2015-2,250 ' R Yes ,No Sump pump? - ElZ } Last month Last date of occupancy: Date Commercial/lndustrial Flow Conditions: , NA Type of Establishment:. ♦ 4 - ♦-' 4 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 i - Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No . , Water meter readings, if available: t5ins♦3/13 - h �' +• r- 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 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name - information is Hyannis Ma 02601 5-16-16 required for every H—y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: _ Date Other(describe below): f General information Pumping Records: - Source of information: ' Owner- Last pump unknown Was system pumped as part of the inspection? ❑ Yes ® No t �. If yes, volume pumped:• gallons How was quantity pumped determined? Reason for pumping. 'Type of System: r ®' Septic tank, distribution box`soil absorption system ❑ Single cesspool ET Overflow cesspool ❑ Privy ` f '• ❑ 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): f5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every �H annis Ma 02601 5-16-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1975 tank and leaching added 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 6 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 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. 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 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 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.).- Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 156 Arrowhead Drive Property Address - Fred Knize Owner Owner's Name information is required for every �H annis Ma 02601 5-16-16 page. Citylrown 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 abo4outlet 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back u or r carry over. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 1 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 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries, number: 4 Hi cap ® leaching trenches number, length: infiltrators ❑ leaching fields C 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.): New leaching was in working order.at time of inspection with no sign of hydraulic failure. Old pit is also dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): r Number and configuration NA Depth—top of liquid to inlet invert t, Depth of solids layer - Depth of scum layer `* Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3113' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ page. Cityfrown 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 — page. Cityrrown 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 REAR I 13 _....,.. ........ .. . jA1-13' 61-50'6" ; �2- IT 132-51' ' A1342' 133-687' A4.23' 84-35' i ! � E l' Ii l,. I I!.............................:............,.._.....:........_..._......_.._ i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ 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 high ground water: 21 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: Perk date 5-17-00 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 156 Arrowhead Drive Property Address Fred Knize Owner Owner's Name information is required for every Hyannis Ma 02601 5-16-16 _ 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Health Complaints 16-Mar-06 Time: 12:10:00 PM Date: 10/25/2005 Complaint Number: 18534 Referred To: DONNA MIORANDI Taken By: DONNA MIORANDI Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: Business Name: Number: 156 Street: Arrowhead Drive Village: HYANNIS Assessors Map_Parcel: Health Complaints 06-Jun-06 Time: 12:45:00 AM Date: 5/22/2006 Complaint Number: 18824 Referred To: DAVID STANTON Taken By: ELLEN WADLINGTON Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: UNSANITARY CONDITIONS Business Name: NumhPr- 156 Street: ARROWHEAD I Complaint Description: TRASH IS PILED HIGH BEHIND MY LOT AT HOUSE ON OTHER STREET, EQUAL TO LARGE DUMPSTER FULL, MATTRESSES, TRASH, DEBRIS "Actions Taken/Results: DS WENT TO SAID LOCATION. NO ANSWER AT DOOR. AN OLDER MODEL MAROON COLORED CAR WAS PRESENT. A SIGN SAYING"SOLD"WAS OUT FRONT WITH DANNY GRIFFIN REAL ESTATE. ' SEVERAL PHOTOS ON FILE. THERE WAS A LARGE PILE OF RUBBISH OBSERVED WITH MATTRESSES AND BUILDING DEBRIS. DS RESEARCHED THE REGISTRY OF DEEDS, BECAUSE ASSESSORS STILL HAD THE SAME OWNER, AND THE REGISTRY OF . DEEDS CONFIRMS THE"SOLD"SIGN. IT WAS SOLD TO A MARIA S. DIAS ON 5-16- 2006. DS WILL SEND A WARNING NOTICE TO THE OWNER. WARNING NOTICE SENT. DS FOLLOWED UP ON 6/1/06, AND THE RUBBISH WAS CLEANED UP. NO FURTHER ACTION REQUIRED. Investigation.Date: " "5/22/2006 Investigation Time: 2:00:00 PM i .� 'f°l� ,`�� � ,,��+ �[ �� -� J,/__� f_ (Il/e .:A•�L' � iti,,, `�e'4 '° � �J3 ^ �•'�„ �. ' - 4 `• t l '�' P.. �,7p'+','l�py.I.N �.r1 � � I e 3' ��4'�, � ti _ i•...�Y7 * f{�j'� ' �ir 'f� �.lt "t' �y 1 ,q -'6�' �• -` \ �' � e .y,x { �.3 w� „y- ��4'�r �t 4' - ai�x f ^I``S r. 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'1 C i , 9 fjj{r S F i f i :g Mom -V0F �BARNSITASB 'W, -MIN W, 110-0110 anya x -�Nez i.Tyrp"t oat ,W WARNING Name, c e f, Of e0 r/Mana o _ .Address o ,Offender MV/MBeg #' `lee z ip Villagie/Stat SSJ -b-'Z ;2 OjIt, on' Name, am/pm; Business e' ' Address s e n -Of facer -6r Sighatur - of M fbkc.ing-- c Village/State/Zip ) Location of,-Offense . r-'A All k. Enforcing 50pt/Div'ision Offense. R coma(,L�6 1 r-.,Jc, - 3s-3- 20of 1019,14 e 4� Facts J. -time nb- legal action"has�-.beeh, tak-en It -This will serve onlyfa.s.Town At this, n agencies to achieve, '-is�'-.the goal of T �roluntdty coinplianc.6 of ow -.Ordinances, Rules and Regulations. Education efforts and. :warning notices are C. attempts. t - "gain ..voluntary compliance Subspquent,' violations - will.-ifleiUlt da k. ippi't Slm ',ap* ___0, y TOWN OF BARNSTABLE BAR-W '; Ordinance ar Regulation F WARNING NOTICE t Name of Offender/Manager ,, Address of Offender - �` �� �� T _ MV/MB Reg.# Village/State/Zip Business Name am pm, on �2077 Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense,; Enforcing Dept/Division Offense Facts This will serve only as a r;arning/ At this time nb legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of, Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. Qj� _ NAM,FfA i"Alk l® s '° K0eMQ < BAR 69179• TOWN OF ADD1NES N FFENOERjL BARNSTABLE� CITY,SPAT, IVIA N T5 ! IV h - � v ` OFFENS , ) or � f L.,..IL'�f fi E_ 0 IIA Ae1.1:. C/ w S MAXY 8AGS aF_ Sty s P /N ', I o .,"ts I > TIME AND DATE 0 IOLATION LOC 0 OF V•L ,,) i,I Z NOT OF c .C i P.M)oN 1 20 SIGNr'tU E ENFORCIG PE2-oh �1 r �Y e E RCING�EP]. o B 0 O: 1 rw VIOLATION 1 Q1} 6�✓ti(3✓U /W 0 OF TOWN l' I�HEREBY ACKNOWLEDGE RECEIPT OF CITATION X Q ORDINANCE $1 Unable to obtain i ai f 'ffe der. 100. � ' THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ Date mailed LU ,OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL Cl-w DISPOSITION WITH NO RESULTING CRIMINAL RECORD. Lt.l CAI REGULATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monda�through Friday,legal holidays excepted, w before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or posts note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:210 Noncriminal Hearings and enclose a copy of this ^/ citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ TOWN OF BARNSTABLE -BAR-W 4900 Ordinance or Regulation WARNING NOTIICE, Name of Offender/Manager \ Address of Offender �(ia APP6o')P,6A n W Jim MV/MB Reg.# Village/State/Zip 01AAMIn rA 0&6 b I Business Name „an/p_m anpow/ 20_ Business Address //( /.( D !f) Signature of rcingf Officer Village/State/Zip n �/ /� ,�/� �,1 'l/J IR6AIA� Location of Offensekq/,,o t y1A)A(& f�f1lbb�C.I//, 7 M 1►ll�� /� ��)�( Enforcing Dept!/ ivision / ` Offense ! �W A OF' �_ �# Facts �#�( -,mO `.A/M A( ( A� �� ��_ O/1 ( � ;; Al),c?� _9 E6 Lj 0(k_� 4 d�Vlrla%la� r�3 Pty)) r PA V 7)& This -will serve only as a warning. At',this time no legal ctiori has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are ' attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. 4! WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. COMMONWEALTH OF MASSACHUSETTS b EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PR TVED a J•�•• OCT 8 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #156 Arrowhead Drive ( O Hyannis, MA Owner's Name: Christine Silviera&Joel Coelho Owner's Address: 156 Arrowhead Drive Hyannis, MA 02601 Z� Date of Inspection: `69/11/02": • Name of Inspector: (please print) Mr. Carmen E. Shay PARCEL Company Name: Shav Environmental Services, Inc. LOT Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ` XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authori ��0F Fails AS Inspector's Signature: Date: 9/11/02 E -� 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow lA► gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments No liquid found in SAS and surrounding stone area. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera &Joel Coelho Date of Inspection: 9/11/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The s stem will Y 9 P P� g Y Y pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of I I - OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Tifl. c i—..o,.t;— n— Aii v)nnn 3 i Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera &Joel Coelho Date of Inspection: 9/11/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r:*io c Incnarr nn P...,,,�ii ci�nnn 4 Page 5 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner, occupant, or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection ? XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up? XX _ Was the site inspected for signs of break out? XX __ Were all system components,excluding the SAS, located on site XX _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of t he baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum ? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no XX _ Existing information. For example,a plan at the Board of Health. XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] T:,iP c Incn t;— V,.—All cnnnn 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Unk. Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on File Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _ Privy I _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: 1998-per Board of Health &Owner Records Were sewage odors detected when arriving at the site(yes or no): No I Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 BUILDING SEWER(locate on site plan) Depth below grade:. 24" Materials of construction: XX cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 9" Material of construction: XX concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' deep x 5'wide by 8' lone (1000 gallon) Sludge depth: 4. 75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffle: 12 How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present and in good condition. Outlet Tee also in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):. i Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine.Silviera&Joel Coelho Date of Inspection: 9/11/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (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.): Two outlets to leaching chambers. D-Box in P'ood condition. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc1_ T;t1A c cnnnn 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number:_ leaching chambers, number: leaching galleries, number: XX leaching trenches, number, length: 1 Trench— 13' wide by 25 feet long,2' deep. 4 infiltrators 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.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone with no evidence of hydraulic failure. 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Trio i—.'t;— P....,, All r'nnnn 9 Page 10 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera &Joel Coelho Date of Inspection: 9/11/02 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. Leach Trench Septic Tank o (1000 Gal.) 0 D-Box D k B A 3 Br House Swine Ties: A -Tank Out—17' B -Tank Out—51' A—D-Box—23' B—D-Box—35' A—Leach Trench E—38' B—Leach Trench—31' Arrowhead Drive 741. c i o . Pr.., A/1 cr1000 10 Page I l of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #156 Arrowhead Drive Hyannis, MA Owner: Christine Silviera&Joel Coelho Date of Inspection: 9/11/02 SITE EXAM Slope Surface water -None Check cellar - Yes' Shallow wells—None Estimated depth to ground water 14 feet below grade. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrangle of USGS Map. Per Barnstable GIS: Elev. of Ground =50 Feet Elev. Of Groundwater=25 Feet Elev. Of Bottom of Leach Trench =45 Feet Therefore: 45 —25 =20 feet separation between Bottom of Leach Trench and Groundwater. Groundwater Adjustment using Index Well AIW230 : 7.7 feet Adjusted Groundwater Separation=20'—7.7' = 12.3 feet (Refer to attached work sheet) Grade=Elev. 50 feet, Leach Trench - D-Box Septic Tank Bottom of Leach Trench=Elev.45 feet Adj. Groundwater= Elev. 32.7 IPermit Number: Date: Completed by: i HIGH GROUNDWATER LEVEL COMPUTATION I ►J�Q A�ca� l)c�V�. �VsGCICI�� Lot No. �Jo� Site Location: ! Owner: S e ddress: Contractor:_ F}'>+ZN�E, Pa`� Address: X (oa�-� r�Q`tfl fin, MPt aas3(o Notes: i i I STEP 1 Measure depth to water table tonearest 1/10 h. .............................................................................. Date Da S i mont / NY Nor t � STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................... A1ty © Water-level range zone .........:.........:...:............. V STEP 3 Using monthly report "Current j .Water Resources Conditions" determine current depth to ^ water level for index well .......................... Doff month yew ( STEP a Using Table of Water-level Adjustments for index well (STEP 2A) current depth to water level for index well (STEP 3), and water-level zone,(STEP 28) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) r i i t L Cape Cod Comn�ission: USGS Well Data - August 2002 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey ((.'SGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For vour convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hy.drologist..Gabrielle._Bel_fi.t at the Commission offices (508-362- 3828). August 2002 ()SGS Site Water Record Record Departure from iNumheir* �:* [Location [Well No. Level* High* Low* Average** (links.to l S(,S Monthly Overall national water-level database) Barnstable ?30 26.3*** 20.5 26.6 -2.3 -2.6 41395607Q1.64301 Barnstable A4W 27.0 20.5 -2.41 . -2.5 1[=414154070165001 Br�wSler BMW 21 13.3*** 6.9 13.3 -3.2L -3.1 ^ 4..1451807Q020�.0.1 Chatham CGW138 25.6 20.9 26.6 -I.5 -1.6 4.1.4.1.O.Q.Q.700.1.11,01 ::\lashpte MIW 29 9.8*** 5.6 10.0 -0,9 -1.3 41.3.525070291904 Sande icl� 21� 48.1 45.9 48.2 -0.3 -0.6 4.1441807024.160..1 Sand��ich SDW 253 54.6*** 45.8 55.1 -4.6 -4.5 414.1.240702.65901 I ruro TS W 89 12.6 10.2 13.0 -0.3 -0.6 42020607004590_l \�%elltlret WNW 12.1 *** 7.3 12.8 -1.6 -1.7 415,'353069585401 11111):.!/\,v\{-w.capecodcomniission.org/wells.htm 9/18/2002 No. �,�®`� Fee �� w THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Kes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Migpogar *pMeut Cottgtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) O Complete System `'Individual Components Location Address or Lot No. P(Q b f t�e Owner's Name,Address and Tel.No. c. a � Assessor's Map/Parcel _t, dl� l N 2 r i ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &k c-C ON Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15 ,ff iCcu,�,7 Ai Type of S.A.S. c,�Ct 1 2P —� Description of Soil 1 C o A j2 SQ a MAO Nature of Repairs or Alterations(Answer when applicable) D—Q t3Y Fo_,2 0 C r _[ Sit a-3:� , Gw SZOe S t&_Q_ << 61 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 E ttal Code and not to lace the system in operation until a Certifi- cate of Compliance hbee�17�st oar ealth. Signed Date Application Approved by Date Application Disapproved for the fo owing reasons Permit No. - Date Issued � � No. 4:�! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZtppYication for 30iopooai bpgtem Con0truction permit ' Application for a Permit to Construct( . )Repair( )Upgrade('i/)Abandon( ) O Complete System 194ndividual Components tip ' U � ` Location Address or Lot No. A Q 1�C� fl f t� Owner's Name,Address and Tel.No. ' Assessor's Map/Parcel a�o L r t N e r i €° Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s�ONrC_ ... Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow �`� 1 gallons. Plan Date Number of sheets Revision Date Title Y Size of Septic Tank x:s' N _ ►fi(.) .�7 A-<< -1 n- li - Type of S.A.S. c Vt Cc.6It c 1 ti 226=;4,L , Description of Soil nekj2 C)A riCQ S+9c tlJ Nature of Repairs or Alterations(Answer when applicable) A t k D- 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 nmental Code and not to lace the system in operation until,a Certifi- cate of Compliance hoe ne n ssued-by-this oard ealth. 7 Signed Date 1//-0�0 Application Approved by Date fn5t Application Disapproved for the following reasons Permit No. Date Issued 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (�` .. artifirate of(compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(/ Upgraded(1/) Abandoned( )by .l -G 2F 5 c 1 a C.— , of i at s (Z Cc nJ . C r� ' - a�a�� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit�I . datedN� � � Ir'staller Designer �t The issuance of thi ernut shall not construed as a guarantee that the sys� will function as Date Inspecto 1 l • No. ��'�Y " Gt --------------- ----------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS :.4 ; ig ogaY *pgtetn.Congtruction Permit Permission is hereby granted`to Construct( )Repair( )Upgrade( Abandon( ) System located at yj 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. w Provided:Construction must be completed within three years of the date of this t. ... 1� / G: Approved b Date: �?G/ '.lz.:. „ " ; I 116199 Y NOTICE: This Form Is To Be Used, For the Repair Of Failed b Septic Systems Only. CERTIFICATION OF SKETCH�MND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERINUT (WITHOUT DESIGNED PLANS) a I hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 1 Sc meets all of the following criteria: L, The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate.is less than or equal to 5 minutes per inch. d' There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed u There are no variances requested or needed. 4/• The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor ethod when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the ma-ximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) Jv, (9 Cam =B) G.W. Elevation the MAX. High G.W. Adjustment . DIFFERENCE BETWEEN A and B 1� SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cat t ' �4 �y. 0 ' ,. a i � 4 �'� TOWN OF BARNSTABLE LOCATION ,L��l Z.-, SEWAGE I , VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �— ' SEPTIC TANK CAPACITY 6 0 I _ "I LEACHING FACII.TI'Y: (type) (size) NO.OF BEDROOMS `J BUILDER OR OWNER j PERMITDATE: COMPLIANCE DATE: OD Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Wbll 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. .. ... ..... CV -C « 7TI [ � Q ,z Qj- CCL co 4 1 V 1 I 71 � o f f r r r Q 3 ; IZL QJ S r1) L-O.0 AT 1 O tom!AS : 1N ST Q►L-LER--S-►J�QNIE-�-A.D-DRE-S-S �� ', i - U -ram • D-ATE-P E-R-t�1T 1 S SU E.D .—_—___—_—_ __ — �rq ' a � It QJ�(� �� /s � is .[•.F ' No......... Fps..... .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH ... ...-.....O F........ :................. ........ ....... :.............. Allp iration -fur Biuvuuttl Works ( ouBtrurtion Vrrui t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys at: ------ .....--- o n Ad or o. Owner Address W .......................... •--------------_-_--- -------••---•--------- -•----••-----•------------------•---•---------dress.. ......_................................. � Installer Address UType of Buildin Size Lot.............................Sq. feet 0-4 Dwelling VNO. of Bedrooms.................�.....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ._ � kT![�.. No. of persons____________________________ Showers ( ) — Cafeteria ( ) Otherfixtures ----•---•---•-•••••----•--•-------------------•--•••----......•--••---•-••------------------------------•---------------------------.-----•=--•------- W Design Flow--_-----��........................gallons per person per day. Total daily flow........... _&.o................gallons. WSeptic Tank—Liquid capacity/4000gallons Length________________ Width................ Diameter___......_._____ Depth................ x Disposal Trench—No. .................... N�Iidtl..................... Total Length.................... Total leaching arca....................sq. ft. Seepage Pit No------------ ...... Diameter.../.1PT9'0_ Depth below i I t................... Total leaching area.___._.. ---------sq. ft. !/ Z Other Distribution box ( ) Dosing tank ( ) !� 2 `r — Percolation Test Results Performed b y Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inc epth of 'Pest Pit_ ....F..... ..__. D th to ground water.............._ O Description of Soil__.__..........._ U •-••••-----•-•-- -- •--••-•--••- -------------------------------------------------------------------------------- *: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----. U Nature of Repairs or Alterations—Answer. when applicable............................................................................................... ••----...-•.................•-••-•----------------••---.........._...---...._....-•---•-----•--•---•--._......------------......_.._...--••-•-------•-------•--•-----••-----.._...__...._...---•-....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issue by hed of health. (%iCp•�1, ------------------------I----- --,�� igned. .. - -- -• - _ Date Application Approved .By------- -... Date Application Disapproved for the following reasons:---•---•--•---•----------••-----•--- ..---••-•--------------------------------------------•-- .........................................................•---•...........-----•-••-------•-....----------......------•...........-•-•-•--•.....----------........----------------...........------------ Date PermitNo......................................................... Issued........................................................ Date _,7 ---------------- Fizz............................ r THE COMMONWEALTH OF MASSACHUSETTS BOARD �EATH ., ........ F....... .............. ..... .. . Vkrtttl,an -fur Disposal Works Tonntrnrtiun Vrrutit . Application is hereby*made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S at: 9 - - ' o' o .Ad s or o Owner Address ;;` ,r s ' a ................................................................................................. ---•-•--•---•-•---------------•-••-••.......--•---............•..........••.................... Installer Address U Type of Buildin .- . Ex ansiori:;Attic Size Lot-Garba a Grinderq feet Dwelling iF N0. of Bedroom p ( ) hoovers gCafeteriarinde ( ) >'Other—Type e of Building ( ) ( ) C4 YP g •�-�a"��++R---No. of persons.................. S a' Other fixtures ..:.........................____ d �..y� ............................................................................................................... W Design Flow-_-_---+1--M. ------------------------- per person per day. Total daily flow...........�1Q---•__.-.._-.--.gallons. P: Septic Tank—Liquid capacity/~gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No:..::...... Diameter.../ Depth below:inlet.................... Total leaching area--__.-. ---------sq.'ft. Z .Other Distribution box ( ) Dosing tank,( ) d 4 - �' Percolation Jest Results `G.- Performed b ` Y :=. ----------••. ---------_..Date........................;'... Test Pit No. 1----------- per inch Depth of "Pest Pit.....`.............. Depth to ground water........................ �14 Test Pit No. 2................minutes �pey inc epth of Test Pit_ ____s...,,:'`_-..-. �to?Vthd water__.__._______o •, ram. Description of Soil....::............ ..... -. ---••--- ------ ---- ------------------- x `, . -----------------------------------------------•--•-•------------------------------------------------•-------------------------------:--......------......----------------------------------------•----- V Nature of Repairs or Alterations—Answer when applicable............:.:......... • ' Agreement The undersigned agrees to install ,the'��foredescribed Individual•Sewage Disposal System•in accordance with the provisions of Article XI of the State Sanitary' Code— The undersigned further agrees not to place the system in. operation until a Certificate of Compliance has beeft issue b thepyrd of health. - igned :: .............................................. * ---- j l : ate Application Approved BY----- - f'= -•-•-••-- = ---. ....... ✓ '�.. ~—�� Date Application Disapproved for the following reasons:.'...:...........::....:_._..................._.........._._..____...._._.._...._........ .................. '`t .......................••--•----•---•----.....---......._••-------=-........--.._.......-•---•-----......------•--._...._...----•••----•--•---...............------------•----............•-----....... 3i Date PermitNo............................................. Issued..................................... _.. ........... . 1•: Date THE COMMONWEALTH OF MASSACHUSETTS i� BOARD OF HEALTH t A t,00.:.Z✓Ll.............OF. ..........................Trrtifirnte .uf Tomplian THIS IS TO CERTIFY, That the Individual Sewage Disposal System.constructed (�) or Repaired ( ) by'.... r --- ..... ----------- - c .. q _ nsta.... has been installed in accordance with the provisions of e X of The State Sanitary Code'as described in the application for Disposal Works Construction Permit �yi`'_4._.._....... dated-._1. ." ....................... THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE CONSTRUED AS A"GUARANTEE THAT THE SYSTEM WILL FUNCTION'.SATISFAGTO•RY•i?.- .--G--- .. Inspector._:_ THE COMMONWEALTH OF MASSAC SETTS , a BOARD O HEALTH - N. t • S� O F — Fd ... .... L -. _ . a Binposal Works C�,unstrurtimi Frrntit Y Perini Sion is eby granted.' '... -- ............. .............................. ............... ._... ........................... .. 77 to Cons c ( ) or Rep ' •'( ) an divid 1.'r age Dis al Syste at No --- r- trees as shown on the application for Disposal Works Construction Pe o._-__._ _ __ x , r .Z .` J Board of Health' , - • DATE = 7 7 .......:.• .< FORM 1255• HOBBS•& WARREN.,INC..'PUBLISHERS„- " I 44 i to r - All, ` = ti23, 450 ;0 1NitLiANi y�N C 9VYE i No. 19334 O. T1 'T}-1a.T'rMC�FUuuDA�vtJ zovi S F�t,�w►J r�►a Tt+-F t� P�A N Ct.►1.y�2►-c.S y�`( �. Iv fv t � , �.�"A: � Iv\e Tovj u ot~ i�..) F?_A+. v t? btu/ CG . ► �.�� NA Ass ,