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0330 BEARSE'S WAY - Health
y 3y0 Be arsesWay , H annis A= 310 009 001 4 u r o 0 � a � I ,,i TOWN OF BARNSTABLE LOCATION '-7-70 47 : ri SEWAGE# �01�— was r VILLAGE�/of/lie9�r�' ASSESSOR'S MAP&LOT /0^00� -001 INSTALLER'S NAME&PHONE NO.ems/ SEPTIC TANK CAPACITY -/��e GQ� LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER / PERMIT DATE: Z^/�a��/,� COMPLIANCE DATE: 1/1'1.// 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) -� ���� Feet Furnished by 1 0. a y - M a p \ M o O t`2 O No. Fee TH COMMONWEALTH OF MASSACHUSETTS Entered in compu er: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplitation for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(vl/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -c- )0 Owner's Name Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �'EVL/_ 5 Designer's Name,Address,and Tel.No. Gc pe Ccd b Ty Woc SeN a� e/ 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. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1�j �1 ��(`(� npo 1 �mG— (j(l1 , ( ,t_) 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 b this Board of Hea Si Date Application Approved by Datea Al Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee TH COMMONWEALTH OF<MASSACHUSETTS Entered in compu er: PUBLIC'H.EALTH'DIVISION - T,„OWN.�QF BARNSTABLE, MASSACHUSETTS Yes 90pthatiou for Bisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(v)"'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. JCc�s l ,I Owner's Nanie;Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. _ Designer's Name,Address,and Tel.No. cc pe C Z6 SepVx_ SeTQ ��- � " c mfoh '0oa d Type of Building: -ti 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) i gpd Design flow provided gpd Plan Date Number of sheets Revision Date - Title _ .., Size of Septic Tank Type of S.A.S. { Description of Soil I Nature of Repairs or Alterations(Answer when applicable) nil 1 C� a 1h - \`\,, aATK\ bcy�,aM n:�)e crew &N-c1< J � Date last inspected: Agreement: a The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code'and not to place the system'in operation until a'Certificate of Compliance has been issued by this Boafd of Heal Si d ��� Date o /� Application Approved by Date` Application Disapproved by t Date for the following reasons Permit No. Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS SQ �-Gr ,�� (J��v X BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓S Upgraded( ) Abandoned( )by at has been constr c ed•n ,co with the provisions of Title 5 and the for Disposal System Construction Permit No. ��ed U '?. t 1 Installer .��n�f t - Designer #bedrooms I V Approved desi . floe gpd r The issuance o this ermit shall not be construed as a guarantee that the system wi `func/ti1on' as des' � ed. Date I Inspector (� �,, 7----------------------- ----.---------------------------------------------- -----------------------------_--- No. / Fee T COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Dermlt Permission is hereby granted to Construct( ) Repair /Jpa e C Abandon( ) System located atzz 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:Construction st b c p t d wit ' hree years of the date of this permit. Date Approved by FFordelivery Information visit our website at VV%VW.usps.com9 n CERTIFIED MAILT. RECEIPT . �'' Onl�.�.No ids"terance Coverage Provided) 0FFIClALfU,-,§ E a . �� . m Postage $ - .9 Certified Fee rA t M Return Receipt Fee gss+mark t O (Endorsement Required) " `y��e, Q, C Restricted Delivery Fee r (Endorsement Required) ps t1: C3 nJ Total Postage&Fees $ • ld• r o� 1999 Group Realty LLC 335 Central-Ave - - Needham, MA 02494 Certified Mail Provides: , • , ■ A mailing receipt l ■ A unique identifier for your mailpieciff ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. ■ Certified Mail is not available for any class of international mail. .i ■ NO INSURANCE COVERAGE IS PROVIDED. with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of,- delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece'Return Receipt Requested'.To receive a fee waiver for' a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement'Restricted Delivery. ;- ■ If a postmark on the Certified Mail receipt is desired,please present the arti- I cle at the post office for postmarking. If a postmark on the Certified Mail �..receipt is not needed,detach and affix label with postage and mail. . I i -IMPORTANT.-Save.this receipt and present it when making an Intjniry.- PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SENDER: COMPLETE THIS SECTION, --COMPLETE THIS SECTION ON DELIVERY 64 ■ Complete items 1,2,and 3.Also complete A. Si nature � � item 4 if Restricted Delivery is desired. L1Rgent ■ Print your name and address on the reverse ❑Addressee so that we can return the card.to you. B. Received by(Pri dfv e) Date of Delivery e Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different Yes,_� 1. Article Addressed to: If YES,enter delivery ad s�el '"�`F °Fr s z NOV-6 2015 1999•Group Realty LLC 335 Central Ave Needham•MA 02494 3. Service Type US4�ssl- 0 ❑Certified Mail® ❑Priority .al Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7014i '1200 i0001 0358 5876 (Transfer from service fabeq 1 ,I , , i, 08 Forin.381 July,2013 Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS •Permit No.G-10 I ° Sender: Please print your name, address, and ZIP+4®in this box° I � I I I I Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 I I . iii i, i,t 1-pliIjI],)ifiii1illj►ddli)fill1l11.i,iilil,i,;i1iIl I ; f ' Barnstable . �VGA� Town of Barnstable Regulatory Services Department AWWWWaM .39. 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# 7014 1200 0001 0358 5869 October 7, 2015 1999 Group Realty LLC 335 Central Ave Needham, MA 02494 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 330 Bearse's Way, Hyannis, MA was last inspected on 8/25/2015 by Michael DiBouno, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • . First cesspool is structurally unsound. You are ordered to repair or replace the septic system within sixty (60) days 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 TH BOARD OF HEALTH c ean, R.S., CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evl\330 Bearse's Way Hy Oct 2015 Town of Barnstable + BARNSCABLB. 059. a Regulatory Services Department 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 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ 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). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts � _ `Tetle S Official lnspeciioh Form.:_ Subsurface Sewage Disposal System F - _ 9 P Y Form Not for Voluntary Assessments 330 Bearses Way Property Address ut---- r� 1999 Group Realt_ LLC Owner -----�---y -----..._.. --.. .._._ ._-._..__..__..__.. __.... ... - ------ ---- - ---- - _ — Owner's Nam information is Qq required for every Hyannis _ Ma 02536 page. City/Town -- .._... _. State Zip Code Date of•Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any•, way. Please see completeness checklist at the end of the form. Important:When . General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return _ ---- --------- ----- —...-- - ...-----._._. ._—._. keY Name of Inspector DiBuono Sewer and Drain rae Company Name 8 Johns Company Address S Yarmouth_ _ _ — -- MA 02664 City/Town —.._..-- --- State -------- Zip Code ---------- 508-364-9587 113522 - l - -- -- -- -- ---._.... ................._._... License Numbe------- ---- ------•----- 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 9/2/15 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. �o VS (Sins•3n3 Title 5 Official Inspection Form:Subsurface Sewage Disposa S stem•Page t of 17 i Commonwealth of Massachusetts r -r� Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a j - 330 Bearses Wa Property Address 1999--GroupRealtyLLC Owner Own --- - ----- --.._..---Owner's information is ••• required for every Hyannis Ma 02536_ - 8/25/15 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: The system contains 3 Cesspools in a series. The first acting as'a septic tank. The second cesspool is currently receiving flow. The last in a series of 3 is dry. The first Cesspool is in need of replacement with a 1500-gallon septic tank as it is structural rV unsound. 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'-for"not determined" (Y, N;ND)for the following statements. If"not determined," please explain. i 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): t�.u;, .',q l5ins-3113 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 330 Bearses Way Property Address 1999 Group Realty LLC Owner — — -------—._..._.—----...---—-----— Owner's Name ---------- ----------- information is required for every HY_annis Ma,.... 02536 8Y25C1'5'. . 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): Replace existing Cesspool with 1500 gallon septic tank ❑ 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 15ins•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 \a 330 Bearses WaY ...._---------...--__-._ Property Address 1999 Group Realty LLC Owner --w- -- Oner's Name, r' :ry information is - • - - - ' required for every t� annis — Ma 02536 _8/25/15 _ _ page.. Cityrrown - -- - 7 _ 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-o'f sbWagemto'facility or system component due-to overloaded or clogged'SAS or cesspool 0 ® Discharge-.or ponding of effluent to th'e•surface"'of the ground or surface waters due town overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts t _ Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 330 Bearses Way,_ Property Address _ --....... ..___.. - - _• .. . 1999 Group Realty LLC Owner Owner's Name -- ---- ------------------ -- -- information is required for every Hyannis — Ma_ _ 02536 8/25/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the-..presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located_in a nitrogen sensitive area (Interim Wellhead Protection Area — IWFA):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•3n3 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 5 of 17 Commonwealth of Massachusetts - � Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 330_B_ears_es Property Address 1999 Group Realty LLC ' Owner _ ..---.....-_ .. . .._ ..-------------------....--------- ' Owner's Name a „ ---- --- ----::, ---.. information is required for every Hyannis_ Ma 02536 8/25/15 page. City/Town State Zip Code'`•' Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes- No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of_sewage.back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the•proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 ------ Number of bedrooms (actual): 5 ------ 1 _. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd,x #of bedrooms): 550—_ - l5ins•3113 Title 5 Official Inspection form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F®rm Subsurface Sewage Disosal stem Sub S p y Form Not for Voluntary Assessments ` 330 Bearses Wa — —Y--- - Property Address 1 Groin Realty LLC--- -----.._.._--- - ------ - - ------- Owner Owner's Name - - - information is required for every Hyannis _— Ma 02536 55 -- ----- -- 8/25/1: City/Town -- ----- _ page. State Zi-_Code'---- ------- ----------------- . . . P Date of Inspection D. System Information (Cont.) Last date of occupancy/use: _ -Date ------------ Other(describe below): General Information Pumping Records: Source of information: Pumped in 2000_--_ 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): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage-Disposal System•Page 8 of 17 Commonwealth of Massachusetts �u� --_-- � Title 5 ®fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A� 330 Bearses Way Property Address 1999 Group Realty LLC Owner Owner's Name u information is H annis Ma 02536 _8/25/15 required for every .--y-----=--------------------------.._..__--- ---- ---T-- ----- — ---- page. City/Town - State Zip Code Date of.Inspection D. System Information Description: The system contains 3 Cesspools in a series. The first acting as a septic tank. The second cesspool is currently receiving flow. The last in a series of 3 is-dry. The first Cesspoat•is in..need-of replacement with a 1500 gallon septic tank as it is structurally unsound._ 2 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 ears usage d 262 GPD _ 9 ( Y 9 (9p ))� Detail: i h Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: - -- - Design flow (based on 310 CMR 15.203): Gallons Per day(gpd) Basis of design flow (seats/person s/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: - - -------- j l51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts —� Title .5 official Inspection form _J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 330 Bearses Way Property Address -------- --- -- — - -- 1999 Group Realty LLC Owner Owner's Name -------- — ------ ---- --- — --- -- information is ., required for every Hyannis _ - Ma 02536. 8/25715 ' page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Approximate age of all components, date installed (if known) and source of information: 50 + ears Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 18" _ — 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.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: Cover to grade — feet — -------- Material of construction: ❑ concrete ❑ metal ❑ fiberglasspolyethylene 9 ❑ � .®-other(explain) Cesspool acting as a septic tank__ If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 3" i5ins•3/13 Tille 5 Official Inspeclion Form:Subsurface Sewage Disposal Syslem,Page 9 of 17 Commonwealth. of Massachusetts _- . _ Title 5 0fficia-1 Inspection Form Subsurface Sewage*Disposal System Form - Not for Voluntary Assessments A 330 Bearses Way Property Address I 1999 Group Realty LLC Owner Owner's Name - -- .---- -----information is is Hyannis _ Ma 02536 8/25/15 _required for every —Y ..-----------------------._. page. City/Town.- _. - State Zip Cpde, . Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24---------- Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42 — -- Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were .dimensions determined Tape Measure _— -- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): First Cesspool needs to be replaced. :;i :- Grease Trap (locate on site plan): NA Depth below grade:' feet- -- ---------- ---- Material of construction: ❑ concrete metal' ❑ fiberglass ❑ polyethylene Elother (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 ISins•3113 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form 11 _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o�•.>=` 330 Bearses Wa Property Address -..,.—... _ .._... ....._-.._. . __... . ----..._---.- - -._.._...._. ,.......__ . 1999 Group Realty LLC Owner Owner's Name -- -- ------ ----- --- - — -- information is required for every Hyannis _ _ --__- - ..__ Ma — 02536 8/25/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place first cesspool needs to be replaced 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 ❑ pol lene eth y y ❑ other(explain): Dimensions: -- --- ------ ---- ----- Capacity: — gallons — Design Flow: _._...----- ----- _------ gallons per day Alarm present: ❑ Yes ❑ No . t Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: — Date ---- comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 151ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts _= -= ' Title 5 .Official Inspecti®n' F®ri� Im Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ate• 330 Bearses Way.... - _ ......._.__.. Property Address 1999 Group Realty LLC Owner Owner's.Name — --- ---------... --------------- ---- — information is C •• -- tto required for every Hyannis Ma 02536 8/25/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Na -- -- --- Comments (note if box is level and distribution to outlets equal, ahy 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•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 i �- Commonwealth of Massachusetts tv Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��•'`• 330 Bearses Way Property Address 1999 Group Realty LLC _ Owner -Owner's Name information is required for every �annis _ Ma 02536 _ 8/25/15 page. City/Town 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: 2 ---- ❑ 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.): Second cesspool is receiving flow. Third is dry Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3 in series Depth -top of liquid to inlet invert Depth of solids layer Depth of scum layer _ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•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' a a 330 Bearses Way Property Address 1999 Group Realty LLC_ =_ - -- OwnerOwner's Name--. - ..•.--- -" -- •--• information is required for every Hyannis _ -Ma 02536 _ 8/25/15 _ page. City/Town ' State Zip`Code'� Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs_of pndin-g or hydraulic failure. i 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.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Assessing AS-BLII-it Cards Palle 1 of ,j KIp 3 =,J TOWN OF BARNSTABL E LOCATION � 7v5 Ps Cuy SEWAGE# VILLAGE �YG L9 y Gr ASSESSOR'S MAP Se LOT 3/0-609.00 :r INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY_ I,S-: C3 f sL�_lm�J c G'F'S Ul i LEACHING FACILITY:(rype) NO. OF BEDROOMS — L Y PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Pi y DATE PERMIT ISSUED; i DATE COLIPLLANCE ISSUED: VARIANCE GRANTED: Yes I I• i 1 33 3�I.7" 3u'S • y"%uc Y-PDC �InGI L.\ PGo littp:/AN,",\aJ.tow,,.barnstable.ma.Lis/Assessin /1-iMdispIay.asp`?mappar=;l 0009001&seq=] 8/?j 01 I Commonwealth of Massachusetts _ Title 5 Official Inspection form`- ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �~ 330 Bearses Way Pr operty Address -- -- —-----— ---------Owner ---- 1999 information is Group Realty LLC --------------------.....-_---------•-----------------Owner's Name --- required for every _.—._ Ma 02536 8/25/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _--_ Title 5 Official Ins' pectin Form -_- - Subsurface Sewage Disposal System'Form - Not for Voluntary Assessments 330 Bearses Way_. Property Address 1999 Group Realty LLC Owner Owner's Name information is required for every Hyannis Ma 025a6' 8/25/15 __ page. City/Town State- Zip Code_ Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ ft 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 — I ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: usgs maps indicat NG at 12+ ft in the area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts V Title 5 Official Inspecti®n ' FO:rrr, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 330 Bearses Way Property Address 1999 Grou RealtyLLC Owner _- —p--- - -------- - ----- ----------_ ----==-= Owner's Name -- ---- - information i — s . . required for every Hyannis----------- --- -- - Ma --- _02538'...-, 8/25/1'5 page. City/Town -- -- -- -- ------._-_ State Zip Code Date of Inspection E- Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information - Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t jowmeentrance .• `'I r u DECK 0- 1 sUder i Front it Y Clikor5 o. y . I Nasnent G-N- t ti 330 Bearses Way — Mirst FRooi° 330 Bearses WayV 2"d Floor Rafrway doset ) •[ i/����L�va-`""r� f_�.. .7°a-'.'��a ""ice, Av closet + � z i Print Page Page 1 of 4 Print this page • Owner Information - Map/Block/Lot: 310/009/001 - Use Code: 1010 Owner Map/Block/Lot GIS 310 /009/ 001 MAPS 1999 GROUP REALTY Owner Name as of LLC Property Address 1/1/12 335 CENTRAL AVE 330 BEARSE'S WAY NEEDHAM, MA. 02494 Co-Owner Name Village: Hyannis Town Sewer At Address: No GIS Zoning Value: RB • Assessed Values 2013 - Map/Block/Lot: 310 /009/001 - Use Code: 1010 2013 Appraised Value 2013 Assessed Value Past Comparisons Building $ 173,200 $ 173,200 Year Total Value: Assessed Value Extra $ 45,700 $ 45,700 2012 - $ 285,700 Features: 2011 - $ 302,000 Outbuildings: $ 2,000 $ 2,000 2010 - $ 338,800 Land Value: $ 67,400 $ 67,400 2009 - $ 394,900 2008 - $ 40400 2013 Totals $ 288,300 $ 288,300 2007 - $ 420,300 • Tax Information 2013 - Map/Block/Lot: 310 / 009/001 - Use Code: 1010 Taxes Hyannis FD Tax $ 576.60 (Residential) Community Fiscal Year 2013 TAX RATES HERE Preservation Act $ 75.77 Tax httn-//tnwn_ha.rmctable.ma._iis/A ssessing/nrintl 3.asn?an=0&searchnarce1=31... 7/16/2015 Print Page Page 2 of 4 Town Tax $ (Residential) 2,525.51 $ 39177.88 • Sales History- Map/Block/Lot: 310 / 009/001 - Use Code: 1010 History: Owner: Sale Date Book/Page: Sale Price: 1999 GROUP REALTY LLC 2007-07-19 C 183677 $1 { OLEARY, JAMES R 2006-08-01 C180765 $400000 FOX, BRIAN K & JUDI A 1999-05-05 C153003 $175000 FLAHERTY, PATRICIA J 1985-06-15 C101931 $99000 CLOUTIER, ARTHUR J 1982-07-15 C89020 $0 • Photos 310 /009/001 - Use Code: 1010 There are not any photos for this parcel • Sketches - Map/Block/Lot: 310 / 009/ 001 - Use Code: 1010 t " t M. As Built Cards:Click card#to view: Card #1. httD://town.bamstable.ma.us/Assessing/printl 3.asp?ap=0&searchparcel=31... 7/16/2015 Characteristics of Cape SPARK residents • Males,ages 12-18 • Clients with a history of abuse/neglect: o Neglect by caretaker o Physical abuse o Sexualabuse • History of behavioral difficulties: o Adolescents who exhibit aggressive behavior ■ Children who have pending criminal charges for violent offenses will be reviewed carefully by the intake team to determine the appropriateness of community based treatment o Running behavior o Conduct disorder and/or severe oppositional and defiant behavior ■ Other DSM-IV diagnosis will be reviewed carefully by the intake team to determine the appropriateness of community based treatment o Sexual acting out behavior • Provocative behavior that places child at risk • Consensual sexual behavior that puts child at risk • Perpetrating/Offending • In these cases,the program will require that there are no known instances of offending/perpetrating within the year prior to referral. In addition,the intake team will require a recommendation and supporting statements from the DCF worker and the child's current therapist that the child has received substantial treatment which justifies a community based placement. o Substance abusers currently receiving treatment o Depression • The program serves youth who are able to function in public school or alternative educational programs • In addition,there are certain characteristics of clients that Cape SPARK cannot serve o Clients who are acutely or actively suicidal o Clients who are mentally retarded o Clients who are actively psychotic o Clients whose acting out behavior presents significant problems for a community based program Contact Information/Point of Contact Director of Children and Families-Jennifer Smith(413)739-5626 X109 Director of Southeast Programs-Shelley Stormo(508)948-9296 Print Page Page 3 of 4 • Constructions Details - Map/Block/Lot: 310 /009/ 001 - Use Code: 1010 Building Details Land Building value $ 173,200 Bedrooms 5 Bedrooms USE 1010 CODE Replacement $251,008 Bathrooms 2 Full Lot Size 0.3 Cost (Acres) Model Residential Total 11 Rooms Appraised $ Rooms Value 67,400 Style Colonial Heat Fuel Gas Assessed $Value 67,400 Grade Mivneus ge Heat Type Hot Water Year Built 1964 AC Type None Effective 31 Interior CarpetHardwood depreciation Floors Stories 2 Stories Interior Drywall Walls Living Area 3,091 Exterior Clapboard sq/ft Walls .Gross Area 5 030 Roof Gable/Hi sq/ft Structure p Roof Cover Aspb/F GIs/Cmp • Outbuildings & Extra Features - Map/Block/Lot: 310 /009/ 001 - Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value FPL2 Fireplace 1.5. 1 $ 3,200 $ 3,200 stories F BFA Bsmt Fin-Avg- 240 $ 3,000 $ 3,000 Partitioned APTX Extra Apartmt 1 $ 11,100 $ 11,100 BMT Basement- 1211 $ 18,400 $ 18,400 Unfinished GAR 378 $ 7,700 $ 7,700 httn-//town.barn-;table_m a.us/Assessing/print l 3.a_Sn?and&searcbnarcel=31... 7/16/2015 Print Page Page 4 of 4 Attached Garage WDCK wood Decking 280 $ 2,000 $ 2,000 w/railings FOP Open Porch- 70 $ 2,300 $ 2,300 roof-ceiling • Sketch Legend Property Sketch Legend B2N Bam-any 2nd story area FPC Open Porch Concrete-Floor REF Reference Only BAS First Floor, Living Area FTS Third Story Living Area SOL Solarium (Finished) BMT Basement Area FUS Second Story Living Area SPE Pool Enclosure (Unfinished) (Finished) BRN Barn GAR Garage TQS Three Quarters Story (Finished) CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished) FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished) FCP Carport KEN Kennel UTQ Three Quarters Story (Unfinished) FEP Enclosed Porch MZ1 Mezzanine, Unfinished UUA Unfinished Utility Attic FHS Half Story(Finished) PRG Pergola UUS -Full Upper 2nd Story FOP Open or Screened in PRT Portico (Unfinished) Porch WDK Wood Deck PTO Patio ' I } iftn- ltnum rIprnct'.iMP rnn ne/Aeeaecinn/rr;v.tl Z nn..7....—Ap------I....---1-^f 1 Print Page Page 4 of 4 Attached Garage wDCK wood Decking 280 $ 2,000 $ 2,000 w/railings FOP Open Porch- 70 $ 2,300 $ 2,300 roof-ceiling • Sketch Legend Property Sketch Legend 132N Bam-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only BAS First Floor,Living Area FTS Third Story Living Area SOL Solarium (Finished) BMT Basement Area FUS Second Story Living Area SPE Pool Enclosure (Unfinished) (Finished) BRN Bam GAR Garage TQS Three Quarters Story (Finished) CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished) FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished) FCP Carport KEN Kennel UTQ Three Quarters Story (Unfinished) FEP Enclosed Porch MZ1 Mezzanine,Unfinished UUA Unfinished Utility Attic FHS Half Story(Finished) PRG Pergola UUS Full Upper 2nd Story (Unfinished) FOP Open or Screened in PRT Portico WDK Wood Deck Porch PTO Patio I . httn•//tnwn.harnctahle.ma._».-,/A s.e�-,ing/nrintl 3.asn?and&searcht)arcel=31... 7/16/2015 F � AS LO?' 9-2 s: . LOT 2 IIr/r/IJ.J♦ .// r/III/III• 'iIII/r!.Iili�'♦ III!//III/. . • • .................... ..'i�V •/III r..r//..../ .r -'/..... . . ...,/ 'f./: '::i'/.o f':�:i' JJII. �' • ,r• SSSa Q• �+, V" yf �g 0 ZIT 3 -fs For "- Tb MoATGjGE INSPECTION uw ZO1V •C• GISTRY OWNERA7'�-00 [2IMM ����Gd�R7'Yr� DEED REF: EUYBR f �.�l g _ _ SCA f;�= . DAY'B PLAN REF: _ — YANKEE SURVEY' TO PRAT TI9 BUILDING �' CONSULTANTS SHOWtI. 02� TttI.9 PLAN is LOCeLEfl OIA TSB UDOUND AS SFOO1iN � ITS POSITCDIi DOES CONFOY0t �, 4q:, sitTB I) �.. TO 7HB ZO NG LAIf SETBACK REQUI MMM- OF � y+�ld- :ems,ROAD A 92452 TOW OF } IT DOSS � LIE Y!t'PNn7 7iiE SPBC1�,1. FLOOD TEL '4.28-�Q054 'MAP D' 4 -5 A EA AS SHO ON 77 ' :,D, w y 77Ml KAN NO'P En. E Molt 29tl CB TO. U9 Office'entrante ' DECK _ o 'S ide slider 0 N bathroom o . s, Front e doors Stairs Basement Stairs _~_�l t 330 Bearses Way — First Floor 330 Bearses WayEr osetr �+ . s 2"d Floor I 4 AN, Stairrnray closet clo set '- o Ik x xc a. I& The ChildreiA StudyHome 1. Statement of Purpose 102 CMR 3.04(1) Founded in 1865 as The Springfield Home for Friendless Women and Children,The Children's Study Home, Inc(CSH), is a 501©3 non-profit based in Springfield that provides educational, residential and community based services to at-risk youth and families in the Pioneer Valley and Cape Cod. CSH believes the family is at the core of a child's life experience, and whenever possible,the family unit should be preserved. The 24-member Board of Directors and the Executive Director oversee staff operations of four residential treatment programs; elementary, middle, and high schools for students with emotional and behavioral needs; and family support, education and reunification programs. State contracts, especially through DCF, are CSH's main source of funding. CSH holds contracts and licensing with DCF, DMH, DESE, EEC and the Hampden County Sheriff's Department through its After Incarceration Support Systems Program. Cape SPARK is a residential treatment program for adolescent boys, ages 12-18 and licensed by the Department of Early Education and Care (EEC).This Program is staffed 24 hours per day, seven days per week. The program can have up to twelve boys and is a four bedroom, two bathroom residence located at 330 Bearses Way, Hyannis, Massachusetts. All residents will.sleep upstairs and be monitored by two awake, overnight staff. There will be two residents in three of the bedrooms and four residents in the larger bedroom. The program utilizes milieu, individual, group, and family therapy where it is appropriate to promote residents progress towards their treatment goals and to the eventual transition to a less structured setting. Family participation is expected, and the residents attend public schools and alternative educational programs. Cape SPARK employs a well-qualified staff consisting of the Director of Southeast Programs, Program Manager, Assistant Program Manager, Clinician, Shift Supervisors, Direct Care Workers, a nurse, and a consulting psychiatrist. Resources in the surrounding area are utilized to provide additional services, such as medical care. The primary client goal is to reintegrate back into the community and/or family setting. Having a family identified at the time of intake is not required; however, if the long term goal calls for family to reunify or for foster care, it would be a service plan objective to identify a family resource and incorporate them into the treatment process. Intake Process Referrals to Cape SPARK are made through the Department of Children & Families and the Area Lead Agencies on a closed referral basis.The Cape SPARK treatment team, led by the Director of'Southeast Programs, reviews the material.The team is responsible for determining the appropriateness of the placement in general and assessing if the program can reasonably service the client/family successfully. If the decision is made that the i r� - The Childrees Study Home placement is appropriate, an interview is scheduled with the family and referring source. Team members assess the client/family during the interview visit. With that information, a formal intake conference is held, and a decision to accept is made. At that time, a plan is developed to transition the client/family into the program.The timeframe from the point of referral to intake should not exceed ten working days.The Clinician and Program'Director are responsible for the entire intake referral process. Services i Services are individualized and either provided or arranged for by the program. Cape SPARK's clinical services are provided by our Licensed Clinician and Masters Level Case Manager. Services available are individual/family/group therapy, daily living skills, independent living skills,therapeutic recreation, community reintegration, skill training, family reunification, adjustment support, drug/alcohol counseling, sexual abuse/behavior management groups, specialized clinical groups, and behavior management skill training.Any service provided will be identified in the client's Individual Service Plan. Characteristics of Cape SPARK residents • Males, ages 13-18 • Clients with a history of abuse/neglect: o Neglect by caretaker o Physical abuse o Sexualabuse • History of behavioral difficulties: o Adolescents who exhibit aggressive behavior ■ Children who have pending criminal charges for violent offenses will be reviewed carefully by the intake team to determine the appropriateness of community based treatment o Running behavior o Conduct disorder and/or severe oppositional and defiant behavior ■ Other DSM-IV diagnosis will be reviewed carefully by the intake team to determine the appropriateness of community based treatment o Sexual acting out behavior ■ : Provocative behavior that places child at risk ■ Consensual sexual behavior that puts child at risk i ■ Perpetrating/Offending • In these cases,the program will require that there are no known instances of offending/perpetrating within the year prior to referral. In addition,the intake team will require a i The Childrees Study Home recommendation and supporting statements from the DCF worker and the child's current therapist that the child has received substantial treatment which justifies a community based placement. o Substance abusers currently receiving treatment o Depression • The program serves youth who are able to function in public school or alternative educational programs • In addition, there are certain characteristics of clients that Cape SPARK cannot serve o Clients who are acutely or actively suicidal o. Clients who are mentally retarded o Clients who are actively psychotic o Clients whose acting out behavior presents significant problems for a community based program Contact Information/Point of Contact Director of Children and Families-Jennifer Smith (413) 739-5626 X109 Director of Southeast Programs-Shelley Stormo (508)948-9296 Department of Early Education and Care HEALTH INSPECTION REPORT This is to certify that (Name of Facility) located at (Street) (City) (Zip) was inspected on by (date) (Name of Inspector) of (Inspection Board, Agency-or Department) The above facility complies with Chapter I I of the State Sanitary Code and other regulations pertinent to the following areas: Kitchen Facilities Yes No Food Storage and Preparation Yes No Water Supply Yes No Hot Water Temperature Yes No Bathroom Areas Yes No Sewage System Yes No Lighting and Electrical Operations Yes No Heat Yes No Ventilation Yes No Smoke Detectors Yes No Exits Yes No Asbestos Yes No Garbage and Rubbish Disposal & Storage Yes No Control of Insects, Rodents & Skunks Yes • No Approved: Yes No *Conditionally 1 RPHealthlnspectionReport20050701 { Recommendations: Signed (Inspector or Representative of Inspecting Authority) *Conditional approval may be given only when, in the opinion of the inspecting authority, children's health would not be endangered in the facility prior to the correction of noted non-compliance items. Conditional approval will satisfy provisional licensing requirements, but certification must be obtained before a regular license can be issued. 2 RPHealthlnspectionReport20050701 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel C� Application #&0 ( " Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address _330 1 �Sst Village Owner H-•- �� 4�'-i Address Se-x-, - Telephone Permit Request S< Square feet: 1 st floor: existing proposed 2nd floor: existing proposed . Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size O •j Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑ Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: I"Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) t'ctt 11-` -e— Basement Unfinished Area (sq.ft) Number of Baths: Full: existing z— new Half: existing new. Number of Bedrooms: -5- existing _new Total Room Count (not incuding baths): existing i� new First Floor Room Count Heat Type and Fuel: 0--Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes Qr10 Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No ----Detached garage: ❑ existing ❑'new size_Pool:`❑-existing-❑ new size _-Barn: ❑ existing-"❑new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ���`����-s s�`�� � `"^t Telephone Number �-L4, 3) 7 3 S- s G - Z 6 Address �� S�� -"� s%�` License # c..s 1 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE - ' 3 ,50 4�I C(I OWN OF BARNSTABLE LOCATION v�v Sys Curl Z SEWAGE # VILLAGE /yG, (,f y 4 f ASSESSOR'S MAP & LOT Oy Clore INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /000C 4&Z,0- oo c, LEACHING FACILITY::(/type) 02 C,,oSS�00IS (size) -6GG NO. OF BEDROOMS r PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER P�t`� �e-7 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Y "PUc �I u� pGo Assessing As-Built Cards Page 1 of 2 �I P/ TO"OF BARNSTABLE I LOCATION $ SEWAGE; VILLAGE y ASSESSOR'S MAP & LOT 6ogcoN' INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY_ —l+S LEACHING FACILITY:(type) QIS (size)inGG yam/ Li NO.OF BEDROOMS Y PRIVATE WELL OR PUBLIC WATER t BUILDER OR OWNER pn4 I DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ! VARIANCE GRANTED: Yes No I I 1 � I 33- ° 3L"?" gU S PC L O•t7 G11ticK��Uw+ I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=310009001&seq=1 8/5/2015 r \ CONIMONTWEALTH OF NLASSACHUSETTS ./� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.' DEPAFLTME?,TT OF-.ENVIR;O'NMENTAL PROTECTIO\T TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM, PART A CERTIFICATION 3� 00q (x Property'ddress: EiQ QQ.n ( Ceram ,3�b Owner's Name: _? Owner's Address: � 'ar- _A a�ev_, Date of Inspection: r. '110 13007 ? Name of Inspect -. (pi.e3se' rint) �� P{' � Company Nam � f �/✓ �� Mailing.Address: 7 Telephone Number: Lj CERTIFICATION STATEMENT I certfiPj 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(3.10 CMR 15.000). The system: Passes Conditionally Passes. Needs Further Evaluation by the Local Approving'Authority, Fails Inspector's SiQhatur . 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 completins this.inspection. if the.system is.a shared system or has a design flow of 10,000 shall submit the report to the:appropriate regional office of the gr.-d or heater, he inspector and t:,a system owner DEP..The prig nal shouidbe sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments I ""''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 under4he same or different conditions of use. Title.5 Inspection For,n 6/15r2000 page 1 Page 2 of I 1 OFFICIAL..INSPEGTIO_N.FORIVI-.NOT FOR YQLtiNI' RI'ASSESSMENTS' SUBSURFACE SE WAGE:DISPOSAL SYSTEM INSPECTION�Oki'M . PART A. CERTIFICATION(continued) Property Address: Owner: Date of Ln ect omJ , .a Inspection�Sum.mary .Check A,B,C,D or E 7-Ah.WAYS complete.all of Section D A. System Passes: I have not found any information which.indicates that any of the failure criteria described in 3 10:CMR 15.303 or in 3 10 CMR.15.304 exist.Any failure criteria.notevaluated 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,.NjND)in the for the following statements. If"not determined"please explain. ' The septic;tank is metal and over 2.0 years old*or.the septic tank(Whether metal or not)is structurally unsound,exhibits substantial infilti-ation or exfiltratiori or.iank failure is imminent:System will pass inspection if the existing tank is.replaced with a.complying septic taril .as approved by the Board of Health. *A metal septic tznk will pass inspection if it is structurally sound; not leaking and if a Certificate of Compliance ind.icatin2 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 obstruciedpipe(s)or due to a.broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board.of Health): broken pipe(s)are replaced obstruction is removed distribution.box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if,(with.approval of the Board of Health): broken pipe(s).are replaced obstruction,is removed . ND explain: Page 3 of 11 OFFICIAL.INSPs CTION:FORIM -NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE.DISPOSAI SYSTEM INSPECTION.'F.ORM PART.A CERTIFIC.ATIOI'd (continued) Property Address: , ., Date of7Apectior./c) - .EZ.O 1(I)9 C. l*urther.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 protectpublic health,safety and the environment. Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within.50 f of of a bordering vegetated wetland or.a saltmarsh 2. : System will fail unless the Board of Health (and Public,Water Supplier, if any).deter..mines that the system is functioning in 2 manner that protects the public health,safety.and environme0t: . _ The system has a septic tank and soil absorption system (SAS)and the SAS is.within I00 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 z 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 faciliry.and the presence of am-r_onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided thatno other failure criteria are t<igzoered. A copy ofthe analysis must be attached to this form. 3. Other: 3. r � Paoe 4 of. 11 OFFICIAL:htSPEC.TION-IFORM:—:NOT FOR VO1LUNTARY:ASSESSMENTS SUBSURFACE SEWAGE-DISP.OSAL:S:3'ST E I��SPECTIOI.FORM PART A CERTIFICATION(continued) Property.Address' — 4 4 'Owner: ' " Date ofyt'spect" n O! D, System Failure Criteria.applicable to all.systems: You must indicate"yes"or"no"to each.of the.following.for a G inspections: Yes N^Q� " U� ' Backup'of sewage into facility or system component due to overloaded or clogQed SAS.or.cesspool Discharse 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.inverrdue to an:overloaded or.clogQed SAS or l cesspool Liquid depth in cesspool is less.than 6" below invert or available volume is less than %day flow Required pumping mare 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 around water elevation. Anyportion.of cesspool or privy is.witfiin 100:feet of a surface:water supply or tributary,to a.surface f water.supply. V .Any portion of a cesspool.or.privy,is within,a.Zone 1 of&public well. Any portion of'a cesspool or privy is within 50 feet of'a.privzte water supply.-Well. 1V Any portion of:a cesspool or-privy is:less than 1.00 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,.fo.r colifor.m.ba.cteria and volatile organic compounds indicates that the.well'is free from pollution.from th'af.fa6lityand the.:presence of ammonia nitrogen and.nitra.te nitrogen is equal.to or less than ppm,.provided thaf no other failure criteria J s� are triggered.A copy of the analysis.must be attached to this form.] (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.Sys te:ms: To be considered a large system the system must serve a.facility-with a design flow of I0'000 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 ProtectiomArea—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 3..10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 ' Pa2e'5 of 1.1 OFFICIAL.INSPECTION FORM—NOT FOR-V.OLVN'TARY ASSESSMENTS SUBSURFACE-SEWAGE'DISPOSAL, SYSTEM INSPE'CTTON FORiNI PART'B." CHECKLIST Property Address: /ty"'� 2', 1� _ b ' Owner: 1�.�?ls.` _X Date of I+n�pectior�c2R-Z ;/Q., =)C06" Check if the following have been done.You-must"indicate`des"-or"no"as to each of the followins: " Yes. No / Pumpine.information was.provided by the-owner, occupant, or Board-of Health. i-Were any of the system components pumped out in the previous two"weeks c� Has the system received normal flows in the previous two week period"? L� Have larze volumes of water been introduced to the system recently or as part of this inspection? Were as built pi_ars of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewase back up ? ' Was the site inspected for signs of break out? (,! — Were all system components, excluding the-SAS,.located"on site (/ _ Were the septic tank manholes uncovered; opened, and.the interior of the tank inspected"ior the condition of the baffies or tees.material of construction, dimensions, depth of liquid,.depth of sludge and depth of scum'? _V11" Was the facility owner(and occupants if different from"owner)provided with information on the proper., maintenance of subsurface sewae"disposal systems The size and location of the Soil Absorption,System-(SAS) on the site has been determined based on: Yes/no e/ Existing"information. For example, a plan at the"Board of Health. 1. Dee'.,-mined in the neld.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CvIR 15.302(3)(b)] 5 Pace 6 of 11 OFFICIAL I3.SPE:CTIO i.FORM=1VOT.FOR:VOI✓UN T'ARY:ASSESSiVIENTS SUBSURFACE-"SEWAGE.DISPOSAL:SYSTEM INSPECTION FORM PARI`•C SYSTEM-INF.ORINIATI ON Property Address: 4 O.wner: , ./ Date of In echo• _ - . FLOW CONDITIONS CV RESIDENTIAL . Number of bedrooms(design): Number of bedrooms(actual).-. DESIGN flow based"on`3 TO`CIvIR I5.203 (for example: 11.0 gpd x' of bedrooms): Number of current residents:. ,, / Does residence have a garbage-- nder(yes or no):A/0 Is laundry on.aseparate sewage system (yes or.no):60.[if.yes separate inspection required) . Laundry system inspected(yes r no): Seasonal use: (yes or no): ✓Y ��� Water meter readings; if avai Lble (last 2 years usage:(gpd)):. Sump.pump.(yesorno): V r Last date of occupancy: COMMERCIALANDUSTRIAL. Type of.establishment:. Design, flow(based.on 310 CMR 15203): gpd' Basis of-desigrr flow(seats/persons/sq.ft,etc.): Grease.trap present(yes:or no):: Industrial wastz 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/user OTHER(describe)` ' :.GENERAL INFORMATION. Pumping Records Sourceofinformation: %. �_ G � 7" Was system pumped as pan of the Inspection(yes or no):/A) Cl If yes, volume pumped: gallons --How was quantity pumped determined? Reason for pumping: i 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.curent operation and maintenance contract(to be obtained from system'owner) y Tight tank! _Attach a copy of the.DEP approval IZOther(describe): qu :✓✓�%C. t�,�J A foximater,,iye of all comporkents, date installe (if known)and solaT-- cf g ,py,7 V. Were sewage odors:detected when'arriVinc, at the.site.(.yes or no): _ 6 f Page 7 of 11 OFFICIAL INSPECTION FORIM' ---NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM-INFORMATION(continued) Property Address: wMA ) . n a (J Owner:\ j'Wj d_ ,�1 ` Date of &pectior�- �/ s •i��,.c t (p BUILDING SEWER(locate on site plan)/ Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water supply well or suction line: Comments (on condition ofjoints, venting,evidence of leakage, etc.): . SEPTIC TANK://V` (locate'on site.plan) Depth below grade: Material of construction:_concrete metal_fiberglass polyethylene _other(explain) If tank is metal..list age:_ is age:conf=ed by a Certificate of Compliance(yes or no):_(attach.a copy of certificate) Dimensions: SIudge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance fi-otn top of scum to tog of outlet.tee or batf e 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. /6 (locate on site plan) Depth below grade:_ Material.of construction:_concrete_metal_fiberglass polyethylene_other (expl'ai ):. 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 orbaffle: Date of last.pLmping: Comments (on' pumping recommendations; inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert,-evidence ofleakaQe, etc.):. Page 3 of 1.1 'OFFI'CIAI:.INSPECTION-FOR.M-—.N.OT.FOR..VOLUNTAR-'.ASSESS)IENTS SUBSURFACE SEW-AGE DISPOSAL, SYSTEM INSPECTIOT1 FORM PART C. SYSTEM hTFORNLATIO (continued) Property Address: ez V Owner. Date of I pectiorf �, > TIGHT or HOLDING TANK: (tank, -be pumped at time ofinspectio'.)(locate on.site plan) Depth:below grade: Material of construction: concrete metal fiber-iass 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: Comm enm(condition o.f alarm and-float switches, etc.): DISTRIBtiTION BOX:Ji) (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 soiids.carryover, any evidence of leakage into or out of box, etc.): 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, etc.): g Page 9 of 1 1 OFFICIAL IitiSPECTION FORYi.—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFA:CE'-SEVIAOE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORDRATION(continued)-'.. Property Address: . 61,4, �. 6L 4.P Owner:\ jam®+ ,_ Date of�ection SOIL ABSORPTION SYSTEMM (SAS): zlocate on site plan;'excnvation not required) If SAS'not located explain why: i Type leaching;pits,number:_ -leaching chambers,number. leachinmalleries, number: leaching trenches, number-, length: e3chimg fields,-nunber, dimensions: overflow cesspool; number: innovative/altemative system type/naive of technology: Comments (note condition of soil, signs of hydraulic failure, }evel of ponding, damp soil, condition of vegetation, etc. - ,V CESSPOOLS:i (cesspool must be pumped as part of'inspection)(locate on site plan) Q,� Number-end configuration: Depth'—too 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, suns of hydraulic failure level of ponding, condition of vegetation, e:c.): ize- 9 c Page 10 of 1.1 OFFICIAL.I3VSPECTION FORM—..NOT FOR'VOLI1i^(TARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORIM PART C . SYSTEM:.INFORMATION(continued). Property Ad'&ss;.a G Owner: j Date off Iq5yection:. i 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. SI,ir)eT r sa�13 j� . � f Paae I 1 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '.30 Owner•- g,01011 1� Date of I. ectio' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water T feet Please indicate (check)all methods used to deternine the high around water elevation: Obtained from-.system design plans on record -If checked,dare of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked:, i local Board of.Health-explain: Checked with.local excavators; installers-(attach documentation) JAccessed USGS'database-explain: You must describe how you established the high ground water elevation: n � mo 1_ � r . . it Permit Number: n Date: Completed by: ~HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ✓�' :� � /V Lot No. Owner:' `� :Address: _.......... `" 7ye%� ve3✓ d Contractor. � ��- Address: Notes: ey STEP 1 Measure depth to water table to nearest 1/10 ft. .......................... ............................. .Date ✓G✓�.d� month/day/year STEP 2 Using Water-Level Range Zone.. and Index Well Map:locate,;...,..;: site and determine:.:......::.._:-:;: OA .Ap.propriate index=:well :::.': ::a:_..... .. ........................ - O Water level range zone ...................... STEP 3 Using monthly�epoFt-?'Current Water::Resources`Conditions watecaevel f.br�index.well._.......... .:.. month/year 7 77- STEP 4 Using Table=of=Water-=level-Adjustments for index::vveJl-=(STEP:2;A),.:current.depth to water-level:for=index--well-(STEP 3), and water-level zone (STEP.2B) _._.___._._,... ==--- -- z c o determine water-level.adjustment .......................................................................................... STEP 5 Estimate depth.to high water by.subtracting the water- level adjustment (STEP 4) from measured depth.to water g level at site (STEP 1) ....................................................:. Figure 13.-Reproducible computation form. 15 Jz i. Department of Early Education and Care HEALTH INSPECTION REPORT This is to certify that (Name of Facility) located at (Street) (City) (Zip) was inspected on by (date) (Name of Inspector) of (Inspection Board, Agency or Department) The above facility complies with Chapter I I of the State Sanitary Code and other regulations pertinent to the following areas: Kitchen Facilities Yes No Food.Storage and Preparation Yes No Water Supply Yes No Hot Water Temperature Yes No Bathroom Areas Yes No Sewage System Yes No Lighting and Electrical Operations Yes No Heat Yes No Ventilation Yes No Smoke Detectors Yes No Exits Yes No I Asbestos Yes No Garbage and Rubbish Disposal & Storage Yes No Control of Insects, Rodents & Skunks Yes No Approved: Yes No *Conditionally 1 RPHealthlnspectionReport20050701 a Recommendations: Signed (Inspector or Representative of Inspecting Authority) *Conditional approval may be given only when, in the opinion of the inspecting authority, children's health would not be endangered in the facility prior to the correction of noted non-compliance items. Conditional approval will satisfy provisional licensing requirements, but certification must be obtained before a regular license can be issued. 2 RPHealthlnspectionReport20050701