HomeMy WebLinkAbout0105 BASSETT LANE - Health 105. Basset Lane
Hyannis
A 309 236 -
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If
No.c;bG � Fee .
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zippfication for bisposal 6pstem Construction j3ertmt
Application for a Permit to Construct( ) Repair( ) Upgrade O Abandon( Complete System ❑Individual Components
Location Address or Lot No. /1� �s� n Owner'snN,ame,Address,and el.No.
Assessor's Map/Parcel (/ ln 10, O
Installer's Name,Address,and Ttl.No. 3��� Designer's Name,Address,and Tel.No.
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Type of S.A.S.
)0escription of Soil lid 14 <
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of e 1
Signed Dat o L f
I.
Application Approved by Date
.Application Disapproved by Date
for the following reasons
Permit No. --3 - Date Issued In
f ' J
No. —t3 J .,1 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entere&in.bomputer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpfication for MisposM *pstem Construction Permit
Application for a Permit to Construct( ) Repair(. ) Upgrade( ) Abandon El Complete System ,❑Individual Components
Location Address or Lot No.loJ ��55 IOwner's{n�N�^ame,Address,and Tel.No. u
Assessor'sMap/Parcel !�S IIJ�s e4 e 1- G K ' 1,
Installer's Name,Address,and el.No. /� (q, esigner's Name,Address,and Tel.No.
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic TAnk Type of S.A.S.
xDescription of Soil
t Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: )
Agreement: ::...,.. .
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title,5 of the Environmental Code and not to place the system in operation until a Certificate of-_
r
Compliance has been issued by this Board of e I
igned VADate
Application Approved by Date
Application Disapproved-by Date
for the following reasons
Permit No. S Date Issued
THE COMMONWEALTH OF MASSACHUSETTS.,_
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS I TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( by
.at has been constructed in accordance
With the provisions of Title 5 and the for Disp sal System Construction Permit No---/R dated
';'Installer Designer
#bedrooms Approved desigD41ow A gpd
The issuance of this permit hall not be construed as a guarantee that the system will nctio as designed. Y
Date 41 j � Inspector �7
/ 3 3S Fees--
No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
.Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandor"r�
System located at� � �nh
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:ConstructioR must f e completed within three years of the date of this ermit.
Date / "i Approved b
Postal
CERTIFIED o .
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a` 53 BOARDLEY-RQAB
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■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
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or Priority Mail®service. ~+ Adult signature restricted delivery service,which
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witti Certified Mall service.However,the purchase (not available at retall). O
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
Insurance coverage automatically included with - accepted as legal proof of mailing,it should bear a
certain Priority Mail items. { USPS postmark if you would like a postmark on rri
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t of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply i r-�
You can request a hardcepy return receipt or an -appropriate postage,and deposit the mailpiece.t3
electronic version.For a hardcopy return receipt -
complete PS Form 3811,Domestic Return 71-1
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
Ps corm 3800,Apra 2ois(Reverse)PSN 7530-02-00a-9047
USPS TRACK NG#
First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
9590 94028 8344 8567 21
United States •Sender:Please print your name,address,and ZIP+4®in this box•
Postal Service - - -
Town of Barnstable.
Health''Division
200 Main Street
Hyannis;MA 02601
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:w :livery address ow: �No
105 BASSET LANE LLC 'yJIMp�
53 BOARDLEY ROAD '
SANDWICH, MA 02563
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❑Adult Signature ❑Registered Mai1T'"
ElWdult Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 4798 8344 8567 21 Certified Mail® Delivery
❑Certified Mail Restricted Delivery Return Receipt for
❑Collect on Delivery Merchandise
^2._Article Number-Cf[ansfeCfiom service label) ❑Collect on Delivery Restricted Delivery. ❑Signature ContirmationTm
{+ t t t ❑Signature Confirmation
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PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic'Retum:Receipt
oF'THE r�
Town of Barnstable Barnstable
Inspectional Services Department 1 Ica
My
• BA RNb-TABLE.
MASS.
,m� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
SECOND NOTICE
CERTIFIED MAIL# 7015 1730 0001 4989 0380
May 29, 2019
105 BASSETT LANE LLC
53 BOARDLEY ROAD
SANDWICH, MA 02563
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 105 Bassett Lane, Hyannis, MA was inspected on
09/01/2017 by Douglas A Brown, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Single Cesspool.
You are ordered to repair or replace the septic system within one (1) year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
ma c ean, R. ., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\105 Bassett Lane Hyannis Second
Notice.doc
y Barnstable
4 � r° ti Town of Barnstablebw-
Regulatory Services Department aicae j
IAENSTABM I '
9 `"�: ,�� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7015 1730 0001 4990 3882
September 19, 2017
SALVATION ARMY OF MASS INC
147 BERKELEY STREET
BOSTON, MA 02116
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 105 Bassett Lane, Hyannis,MA was inspected on
09/01/2017 by Douglas A Brown, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Single Cesspool.
You are ordered to repair or replace the septic system within two ( )years from the date
you receive this notification.
Failure to repair/replace.the septic system within the deadline period will result in future
enforcement action.
&PERORDER OF T OARD OF HEALTH Y,Kean, R.S., CHO
Agent of the Board of Health
I
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\105 Bassett Lane Hyannis.doc
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,� Town of Barnstable Barn
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Inspectional Services Department "AmedcacRy
BARN$TABLE.
""'1639. Public Health Division
�0 m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
SECOND NOTICE
CERTIFIED MAIL# 7015 1730 0001 4989 0380
May 28, 2017
105 BASSETT LANE LLC
53 BOARDLEY ROAD
SANDWICH, MA 02563
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 105 Bassett Lane, Hyannis, MA was inspected on
09/01/2017 by Douglas A Brown, certified Title V Septic Inspector for the State of
• Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Single Cesspool.
You are ordered to repair or replace the septic system within one (1) year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas c ean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\105 Bassett Lane Hyannis Second
Notice.doc
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Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mallpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this h
delivery. USPS&postmarked Certified Mail receipt to the,;
n A record of deliveryretail associate.
(including the recipients M
signature)OSt is retained by the Postal Service— Restricted delivery service,which provides ftl
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent p
Important Reminders: Adult signature service,which requires the _TI
o You may purchase Certified Mail service with signee to be at least 21 years of age(not _U
First-Classtlail®,First-Class Package Service°, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age,
International mail. • and provides delivery to the addressee specified I
a Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agentl
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a I
certain Priority Mail items. USPS postmark if you would like a postmark on f1-
a For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailplece,you may request Certified Mail item at a Post Office'for f,
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion J
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply F"
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.L3
electronic version.For a hanlcopy return receipt, *• r1
complete PS Form 3811,Domestic Return • ►: `;; '_ �: `' ��
Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
Ps Form 3800,Apn12015(Reverse)PSN 7530-02-000•e047 +'
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o 1 ram,
Town of Barnstable Barn
f �
Regulatory Services Department ;mCae y
IAMSTABM
MAM 039 Public Health Division
9�A i639 `0g' m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7015 1730 0001 4990 3882
September 19, 2017
SALVATION ARMY OF MASS INC
147 BERKELEY STREET
BOSTON, MA 02116
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 105 Bassett Lane, Hyannis, MA was inspected on
09/01/2017 by Douglas A Brown, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Single Cesspool.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
&PERORDER OF T OARD OF HEALTH
Kean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\l05 Bassett Lane Hyannis.doc
r +
Town of Barnstable
�w.Ruc�.wr r• : Regulatory Services Department
pTED►AA��
Public Health Division
200 Main Street,Hyannis MA-02601
Office: 508-862-4644 Richard Scali;Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 63 2007
Rev. 5111116
DEADLINES TO'REPAIR FAILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
.An`)e'marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA.
' a Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
Pipe
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to,an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water,quality analysis. (This system passes if the water analysis
indicates the well is free from pollution .
2 YEAR DEADLINE
00
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M
105 Bassett Ln j1k
Property Address
Salvation Army
Owner Owner's Name
information is
required for Hyannis MA 02601 9-1-17
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out s�#jt /a�(Q 0
forms on the
computer,use 1. Inspector:
only the tab key
u
o move your DOUGLAS A BROWN
cursor-do not Name of Inspector
se the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
�II°D Cityrrown State Zip Code
508-420-4534 S14297
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
9-1-17
lnspecteV§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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
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:
Single cesspool automatic 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 Forth: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
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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 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
't 105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is
required for Hyannis MA 02601 9-1-17
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
riTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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.
❑ 0 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two.week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
❑ ® Was the site inspected for signs of break out?
❑ [K 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): Number of.bedrooms(actual):
I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
I
t5ins-3/13 Title 5 Official Inspection Forth: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
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
At time of inspection a single cesspool was found. There was an as-built card showing a septic tank
and pit but this was not located on site unless it is possibly under the asphalt parking lot.The
cesspool that was found did have one pipe that was heading towards the building so lam assuming
that this is the only system on this property.
Number of current residents:
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: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: retail
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: vacant building usage not available
t5ins•3113 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 105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is Hyannis MA 02601 9-1-17
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: unknown
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
❑ Overflow cesspool
❑ Privy*
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/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•3113 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
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
appears to be original
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 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: 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:
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
105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
L Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 105 Bassett Ln
Property Address
Salvation Army -
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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:
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
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bassett Ln
Property Address
Salvation Army
Owner owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Cityfrown 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
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 Forth: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 "t 105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
'❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
A single cesspool was found on this property.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction block
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bassett Ln
Property Address.
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Forth: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
'< 105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Citylrown 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
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
. ' 105 Bassett Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every 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: 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:
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
a 105 Bassett'Ln
Property Address
Salvation Army
Owner Owner's Name
information is required for Hyannis MA 02601 9-1-17
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 1 of 2
LO CAT lot SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
RUILOER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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C. e5 s Q
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=309236&seq=1 9/3/2017
EAm
Massachusetts Fire Incident Repo
Hyannis Fire Department
r
Date of Time Of
FDID` Incident No. Exposure #. Incident Day of week Call Time Service
01922 A230955 0� 4/2 0 0 3 Thursday 50 11 :31 11 :34 12:01
Address zip Census Tract
1 0 5 Bassett Lane Hyannis 4 0
Type of Situation Found Type of ction Taken Mutual Aid
47 Chemical Emergency 471 4 Remove Hazard
Fixed Property Use I nition Factor
"clothing Store." 5 2 1 00 No Fire Found
Occupant Name Occupant Telephone
Salvation Army Thrift Store 5 0 8-7 7 1 -8 9 8 2
Owner Name Owner Address Owner Telephone
Salvation Arm Thrift Store 105 Bassett Lane 5 0 8-7 71 -8 9 8 2
Method Of Alarm Shift No Of Alarms # of Personnel Responded
i Hazardous
1 Telephone 1 B 1 4 Materials
Engines Tankers Aerial Other Vehicles Present
001 0� p� p� Yes
Fire Service Other Injuries
Injuries U� Fatalities 0] Injuries 0� Fatalities � Rescues 0�
Mobile PropertV Use ❑ Is Car Stolen Insurance Company
Mobile Property Make Year Model Color License Number VIN
0 0 0
Complex Area Of Origin
Estimated
Loss
Equipment Involved In Ignition Form Of Heat Of Ignition
0
If Equipment Was Involved In Ignition
Material Ignited Year Make Model Equipment Serial Number
0
Method of Extinguishment Level Of Fire Ori in Number Of Stories
1-J 0
Construction Type Detector Performance Sprinkler Performance
Extent Of Damage
Flame Smoke
Material Generating Most Smoke Type Of Material Generating Most Smoke
0
Avenue Of Smoke Travel Weather Conditions Commanding Officer
0 R aanin ...................... p....................................... Cat C. Farrenko f
Report By JCapt C. Farrenkopf
HYANNIS FIRE DEPARTMENT - INCIDENT REPORT
COMMENT PAGE
Qncident No. IA230955 Address 105 BASSETTLANE
Date of Report 9/04/2003 ommanding Officer Capt C. Farrenkopf
Report By lCapt C. Farrenkopf
FIRE ALARM RECEIVED A CALL FROM A MS. MERRI HAMBLIN AT 105 BASSETT LANE, SALVATION ARMY
THRIFT SHOP REPORTING THEIR FIELD PERSONNEL FOUND SEVERAL CONTAINERS OF FOREIGN MATERIALS IN
THE STORAGE SHED ALONG SIDE THERE BUILDING. CALLER REQUESTED WE SEND SOMEONE BY TO CHECK
THEM.
ARRIVING ON SCENE,SIDE ONE,ONE STORY,METAL SPACE BUILDING,OCCUPIED,STORAGE SHED ON SIDE
TWO WAS OPEN AND BEING EMPTIED BY EMPLOYEES.
INVESTIGATING WE FOUND SEVERAL SMALL CONTAINERS OF CHEMICAL USED IN DEVELOPMENT OF FILM. ALL
CONTAINER APPEARED TO HAVE BEEN OPEN AND PARTLY USED,SEE LIST BELOW. BOARD OF HEALTH WAS
NOTIFIED BY FIRE ALARM WITH AN E.T.A.OF ABOUT TEN [10]MINUTES.
INVESTIGATING FURTHER DONNA FROM THE BOARD OF HEALTH ARRIVED ON SCENE,WE EXPLAINED THE
SITUATION AND SHOWED THESE CONTAINERS.TO HER. FINDING ALL CONTAINERS CLOSED[SEALED WITH
LIDS]SHE DETERMINED THAT THESE CONTAINER COULD BE REMOVED TO THE TOWNS HAZARDOUS
MATERIALS COLLECTION CENTER AT THE NATURAL RESOURCES ON PHINNEY'S LANE. CONTAINERS WERE
PLACED IN A COOLER,TAPED SHUT,AND TRANSPORT IN 800 TO THAT LOCATION WHERE DONNA WAS GOING
TO PLACE THEM IN A PROPER CONTAINER FOR FURTHER DISPOSAL.
LIST OF PRODUCTS: PHOTO DEVELOPING SUPPLIES.
YANKEE INSTANT FILM DRYER.
KODAK INDICATOR STOP BATH.
FLEXOGLOSS SOLUTION
KODAK PEON PRO 200 SOLUTION `
BERK TONING SOLUTION X THREE[3]BOXES.
THREE EMPTY MIXING METAL CANISTERS.
CAUSE:CARELESS DISPOSAL.
i
FF.SWOSZOWSKI, FF.HENNESSY, FF.HANSON.
WEATHER CONDITION: RAINY,WARM,WIND OUT OF THE SOUTHWEST ABOUT 8 MPH,T 800 F.
FARRENKOPF, C. CAPT. 09/04/03.
Health Complaints
04-Sep-03
Time: 11:55:00 AM Date: 9/4/2003 Complaint Number: 4261
Referred To: DONNA MIORANDI Taken By: DONNA MIORANDI
Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE
Article X Detail:
Business Name: Salvation Army
Number: 105 Street: Bassett Lane
Village: HYANNIS Assessors Map_Parcel:
Complainant's Name: Hyannis Fire Dept.
Complaint Description: Hyannis Fire called to state that they were on
the scene at the Salavation Army where
someone unknow had discarded old
photochemicals and some equipment.
Actions Taken/Results: DZM arrived on site and observed the used
photochemicals of fixer and film dryer, toning
solution, etc. The Salvation Army did not have
the money to dispose of it properly so the
solution was to take it to the hazardous waste
locker located at Natural Resources. Fire Dept.
transported chemicals and followed DZM to the
locker where it was put under lock and key.
Investigation Date: 9/4/2003 Investigation Time: 12:05:00 PM
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SORRY WE MISSED YO
DATE TIME
❑ WILL CALL AGAIN Date
Q PLEASE CALL FOR RESCHEDULE
❑ ITEMS NOT TAGGED
❑ SORR
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Reason
Driver Truck#
SALVATION ARMY
ADULT REHABILITATION,CENTER
281 MAIN-STREET
BROCKTON, MA 02301
(508) 586-1187
LOCATION SEWAGE PERMIT NO.
ERMaNO.
VILLAGE
-Z S
INSTALLER'S NAME A ADDRESS
I U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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