The URL can be used to link to this page

Home My WebLink About0460 BEARSE'S WAY - Health 460 Bearse's Way: A __ 292 006 e I ' i e � I Commonwealth of Massachusetts a9a- 006 Title 5 Official - Inspection Form • Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address 1`0 Wayne Petty Owner Owner's Name information is Hyannis MA 02601 6-18-19 required for every ' page. City/Town State Zip Code Date of Inspection �? Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Im ortant:When ``�� ,.• S9ci�' filling out forms A. Inspector Information 39��- �� y�- onthecomputer, James D.Sears �; JAMES m use only the tab _ key to move your Name of Inspector cursor-do not Capewide Enterprises use the return Company Name '3y � • �.` key. ,, F '' ' 153 Commercial Street yiq„1h INS?"- "�� Company Address '..' Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number I B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails aa��_IXAA r�� 6-19-19 I ectoes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 is a 1000 Gal. Tank and pit. 2) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health; safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is MA 02601 6-18-19 required for every Hyannis page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) i � Yes No Static liquid level in the distribution box above outlet invert due to an overloaded AZ,4 ❑ ❑ or clogged SAS or cesspool ❑ ® Liquid depth in 42EB=is less than 6" below invert or available volume is less than '/z day flow Piz' ❑ ® 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 water supply 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 2000 gpd- ❑ ® 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® 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? i ® ❑ 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)] t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: I Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No I Does residence have a water treatment unit? ❑ Yes ❑ No I If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ./ 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Retail - Office's Design flow(based on 310 CM 15.203): 512 Gallons per day(gpd) Basis of design flow,(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: na Last date of occupancy/use: Present Date Other(describe below): 3. Pumping Records: NA Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 18 i Commonwealth of Massachusetts _S Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 42" 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.): Pipeing is 4" PVC SCH -40. t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way - �" Property Address Wayne Petty Owner Owner's Name information is required for Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 32" 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 1000 Gal. Precast Dimensions: 211 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness O Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA � How were dimensions determined? Asbuilt-Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 32" below grade w/center cover steel at grade. Note: In and outlet covers under blacktop No sign of leakage or over loading. Note: Maint pump after inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is Hyannis MA 02601 6-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: I ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Box 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a H-20 Precast Pit. Pit at 42"below grade w/steel cover at grade. 10"water in pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r t Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is Hyannis MA' 02601 6-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is Hyannis MA 02601 6-18-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insP.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Jun.13 19,09:36a Capewide Enterprises 508-477-4977 p.11 460 &WX w TOWN OFBARNS TAB L B LOCATION SILO &i!'S'et SEWAGE N VII.LAGE ASSESSOR'S MAP&LOT_`2 Z�•0_(� INSTALLER'S NAME A PHONE NO. f SEPTIC TANK CAPACITY LEACHING FACMr Y:(type) (size) NO.OF BEDROOMS fl BUILDER OR OWNER m a mil) Ka►r n CCira n PERMITDATE: COMPLIANCE DATE: - Separation Distance Between ft: Maximum Adjusted Oroundwa er Table to the BOttOm of Leachi ng Facility Feet Private Watu Supply Well and Leaching Facility (if any wells exist oa Site or within 200 feet Of leaching facility) Feet Edge of Welland and Leaching Facility(If any wetlands exist within 300 fat of leaching fadlity) Furnisbed by O.0; A � A 0 1 I n's 2rr5 2 z6 1%,5 2 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'-6" 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: T H 12'-6" NO G W Bottom of pit at 4' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 460 Bearses Way Property Address Wayne Petty Owner Owner's Name information is required for every Hyannis MA 02601 6-18-19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included N0 G-w 15insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 j' ;TOWN OF BARNSTABLE LOCATION S? AtPi✓`Ses 66, SEWAGE # VELLAGE- rt n h;c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �� vr�✓1___ _ SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) (size) NO.OF BEDROOMS C) BUILDER OR OWNER M ax-S" 'f- Ka✓• Y1 PERMTFDATE:- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 3W feet of leaching facility) Feet Furnished by �f L y I ® 1. 1 2'j,15 21 1 5 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS (I/ -- o DEPARTMENT OF ENVIRONMENTAL PROTECTION =r DEC 0 12004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 4 ,WAP Property Address: _5, ,6�.1L4AJ1-1)/ S, Y",4 . PARCEL - IDo �D Owner's Name: C_4f?0'j LOT Owner's Address: p af»l 7y� •� - So. •N_A 02G G ti Date of Inspection: quto en Name of Inspector: (please print) Company Name: DAN A. SPEAKMAN N•lailing Address: Construction 15 Speak Way 'I'elephoue Number: North Harwich, MA 02645 ('F,RTIFICATION STATEMENT I certify that I have personally inspected:"the sewage disposal system at this address and that the inf6rmation reported bclo%v is true,accurate and complete as of the time of the inspection.The inspection was performed based on my Irainiil'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: ---P-asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Ins ector's Si nature: F Date: 4 y. 2 J O':/ The systeiti inspector shall submit a copy of this inspection report to the Approving Authority(Board offlealth or I)l.:I') within 30 days of completing this inspection. If the system is a shared system or has a design Flow of 10,000 s_pd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DF.P. The original should'be sent to the system owner and copies sent to the buyer, if applicable,and.,the approving onilhority. '. Notes and Comments' S[--PT/e Ti�f-Jf� aJE S tit'4�-`1T��1GE�U"�i°�`uci. —This report only describes conditions at the time of inspection and under the conditions of use at that time. "rhis inspection dues not address how the system will perform in the future under the same or different conditions of use. 0 I ills Inspection Form 6/15/2000 page I Pau _' ol I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Y(e0 � (honer: ---- Date of Inspection: .OLVI 1z O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ,--I-liavc not found any information which indicates that any of the failure criteria described in 310 CM.R I i.30.i or in 3I0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Cummcnts: B. System Conditionally Passes: Al 1/ One or more system components as described in the"Conditional Pass"section need to be replaced or rcpaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Ansv er yes., no or not determined (Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsOund. exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existin'u tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ohstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection il'(with ;ipproval of Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: fhc system rewired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection il'(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: f OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46P t7 z'6:;qeSe;S W/' Owner: C7 Datc of Inspection: _ /f D 4'/ C. Further Evaluation is Required by the Board of Health: �7 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is I'ailin" to protect public health, safety or the environment. 4 I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _l'he system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet o1'a surface water suppl.y,or tributary..to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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•hut 50 feet or more from a private water supply well". Method used to determine distance *`This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. W 3. Other: i•, ; i.,. ,.,,• ;,,., r. .., �ii ci�nnn 3 f;icc 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: SFogy?S6- 9 . Owner: ?o Ihi(c of Inspection: 1). System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for�11 inspections: ; 4 Ycs No mockup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ., ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,---,}tatic liquid level in the distribution box above outlet invert due to an overloaded,or clogged SAS or cesspool -- uid depth in cesspool is less than 6" below invert or available volume is less than 'IA day now . -.1kequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number oftimes pumped.__. vfity 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 I of a public well. .-A iy portion of a cesspool or privy is within 50 feet of a private water supply well. iiy portion of a cesspool or privy is less than 100 feet but greater than.50 feet from a private water supply well wiff no acceptable water quality analysis. This system passes if the well..-Water..analysis, performed at'a DEP certified laboratory, for coiiform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and`nitrate nitrogen Is equal to or less than S ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.l (Yes/No)The system (ails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. F. Urge Systems: AJ 1 '1'0 I)c considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. YOU must indicate either"yes"or"no"to each of the following: t fhc following criteria apply to large systems in addition to the criteria above) d yCS no Olt S)stenr;is within 400 feet of a surface drinking water supply the systenr.Iis 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— I WPA)or a mapped Zone 11 of a public water supply well II Vou leave answered "yes" to any question in Section E the system is considered a significant threat, or answered •.\cs- in Section D above the large system has failed.The owner or operator of any large system considered a .,_nili�1nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM I S.04. The system owner should contact the appropriate regional office of the Department. r:,i., c ,• �,,,,, ,.., 4 An cnnnn Pa,c of, ll OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B rr CHECKLIST Property Address: 4(O Cee cSf.li kl,1 Owner: Datc of Inspection: II C•hcck if the following have been done. You must indicate"yes"or"no"as to each of the following: •d Ycs No mping information was provided by the owner,occupant,or Board of Health �_iFiere any of the system components pumped out in the previous two weeks ✓ Has the system received normal flows in the previous two week period .' �`Yt'ave 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 ol'tlic 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 (lie 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: Ycs no Fxisting information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria relato to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 1',1u-c6ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: +t'O z'FATI S&Z Owner: O Dale of Inspection: FLOW CONDITIONS RESIDENTIAL AJ Nurnbcr of bedrooms(design): _ _ Number of bedrooms(actual): I)I:SI()N Ilow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): Number of current residents: Dues residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no):_ [if yes separate inspection required] Laundry system inspected(yes or no):_ scasunal use: (yes or no): _ Wa(er meter readings, if available(last 2 years usage(gpd)): tiunlp pump(yes or no): — I..ast date of occupancy: C'OMMERCIALANDUSTRIAL C I�-pc ul'cstablishment: �lml( s Design flow(based on 310 CMR 15.203): 512 fi gpd J Basis ol'design flow(seats/persons/sgf3,etc.).. =So 4,/ ,0 /ebo = Z---p Of�iC�= �J�P. 0./ioo�C=ZCoZ-j Grease trap present(yes or no): OJO Industrial waste holding tank present(yes or no):`Uc Nun sanitary waste discharged to the Title 5 system(yes or no): �o Watcr meter readings, if available: y,f MD C F, ,1a t,4, y'io'U C.F Las( date ol'occupancy/use: P5e SEaT— O-f I-1 E12(describe): GENERAL INFORMATION Pumping Records Sourcc of information:_ Was system pumped as part of the inspection(yes or no): AVO I I'ycs. vulunle pumped: _gallons-- How was.quantity pumped determined? _ Reason for pumping: TYPE: OF SYSTEM . optic lank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy d. S1larcd system (yes or no)(if yes,attach previous inspection records, if any) 111110vativt"Alter,pative technology. Attach a copy of the current operation and maintenance contrIct rib be obla111ed I'rorll system owner) 1 l ieht tank _ Attach a copy of the DEP approval Other(describe): Apprueirllate age ofall components,date installed(if known)and source of information: 4Wcrc scwauw odors detected when arriving at the site(yes or no): �C1 Pace 7 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (Dunes: 64 / On-� Date of Inspection: 2� o IIIJILDING SEWER(locate on site plan) Depth below grade:C-.� S Cj s Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): tiEPTIC TANK: cate on site plan) Depth below grade: :SC,_� C Z. e0vE1t 1 To �i44c Material of construction:—:errcrete_metal_fiberglass_polyethylene i other(explain) I I'lank is Metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) I)111en"1011s: SlUdge depth: Distance from top of sludge:to bottom of outlet tee or baffle: ? Scum thickness: < I)istancc I"rom top of scum to top of outlet tee or baffle: /c> —? Iistance from bottom of,scum to bottom of outlet tee or baffle: low were dimensions determined: /174SASVJZE,,') C'omnients(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): /49vE , ...�.._.�.e.-C S�—�� ✓tii �Al 1 c\1 C 9 -- GREASE..TRAPW—hlocate on site plan) Depth below grade: — Material of construction:_concrete_metal__fiberglass_polyethylene_other (c.N p l a i n):...-------=-- ' d SCUm thlC1{11CSS: - _ �.' Distance fronldop of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumpM (.oll mellIS(On pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 8 of' ll OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: �Ceo �Et1 USES7� Owner: Dale of Inspection: // or HOLDING TANK:44(tank must be pumped at time of inspection)(locate on site plan) [)cpth below grade: Material ofconstruction: concrete metal fiberglass__polyethylene other(explain): Dimensions: _ Capacity: -.---------gallons Design Flow: ____ ___gallons/day Alarm present(yes or no): Alarm level: _ _ Alarm in working order(yes or no): Datc of last pumping: Comments(condition of alarm and Float switches,etc.): DISTRIBUTION BOX:�r (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 Icaka,.;e into or out of box,etc.): I'UMP 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.): 8 11a,ue 9 ol' I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: y(po /3Ef��SESw9Y Owner: Date of Inspection: 14 2 SOIL ABSORPTION SYSTEM (SAS): ✓locate on site plan,excavation not required) II'SAS not located explain why: v 'rype caching 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.): G..... sTa =.U iT- G�c� d c.tvc`�C� Z.5 AEG o c.v t�'�2 T, Aj __j zr - - F L.,Lc ZU T �0 S � .� P�-yt�=o.�dw �s� �, !� c.40_:-J C, . -,J o Pdw7" 770-J. C:I?SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) i Number and configuration: Depth . top of liquid to inlet invert: j Depth ofsolids layer: Dcpth ofscum layer: Dimensions of cesspool: i'vtaterials 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:k14 (locate-on`site plan) Materials ol'conpruction: Dimensions: _ 17cpUi of solids: —_--�— Conuiicnts(note cotiditio_ n of soil,7gns of hydraulic failure, level of ponding,condition of vegetation:etc.-.)': ;.�•. ; �,,,•,...,• ,., r .• , �ii cnnnn 9 Pa,c 10 of' I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: D Date of Inspection: // 2 a Y SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference•land.marks-or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. G"IT V✓ / Zo IV60 j �o' �l° wti"'o'`'�� S /C � D N y LP v 10 Pace I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L��oc7,dE�iuES 4�i4 Owner: O Date of Inspection: SITE EXAM Slope Surlace water Check cellar ; Shallow wells / Estimated depth to groundwater feet A W770^1 Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: 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: C. /9 0 i, of �/� S �QZr/Wr _ 5, R c 4 TZr_Yt /1 0 S, i s Et = 3 G ' Y. II TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1. Marine,Gas Stations,Repair nters BOARD OF HEALTH satisfactory 3.2.A to Body Shops O unsatisfactory- 4.Manufacturers COMPANY �'C1'� ti" �-�� 1 (see"Orders") 5. Retail Stores 6.Fuel Suppliers ADDRESS ��5 ��`I Class: .°2 7.Miscellaneous *fckno1� QUANTITIES AND STORAGE (IN= indoors; OUT-outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: PA DISPOSALIRECLAMATION REMARKS: 1. §anitary Sewage 2.Water Supply Town Sewer e--(S&ublic O On-site OPrivate 3. Indoor Floor Drains YES Nd�- O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES N6 — ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Narne of Hauler Destination Waste Product YE INO 1. 2. n Person(s) Interviewed Inspector Date Date: 3 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: `csr �Ou4t'o l BUSINESS LOCATION: L'I D fa1S'e—!S L�J S INVENTORY MAILING ADDRESS: �� TOTAL AMOUNT: TELEPHONE NUMBER: SO 8-77d — �7 7Z-7 6-m.S CONTACT PERSON: EMERGENCY CONTACT TELEPHONE N MBER: MSDS ON SITE? TYPE OF BUSINESS: caA t,vi akwce_ r'e,+ P,.2- INFORMATION/RECOMMENDATION I L&107A-e' Fire District: e �- 3 uJ "A a*7rU' -T .e/cam// •� ,, , h Q.-.0 I'yl IJ'iPiJzska' !g &V/h . Waste Transportation: A10 Last shipment of hazardous.waste: Name of Hauler: Destination: Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, s rage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) 3 Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED 23 Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor& furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers OXI r (including bleach) Spot removers &cleaning fluids I (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r TOWN OF BARNSTABLE � jw+,0q TOXIC AND HAZARDOUS MATERIALS ON-SIT VeNT ORY NAME OF BUSINESS: ` r" t�Q �'��• BUSINESS LOCATION: LA 640 J3 Ccvgse4s I_Al AaGtA'Zd'f-tS INVENTORY MAILING ADDRESS: if '� TOTAL AMOUNT: TELEPHONE NUMBER: 6_0 9-779 V 72--7 _ 1 S1 gawnn s CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: tA- - INFORMATION/RECOMMENDATI( Fire District: e J t* 3 Waste Transportation: a/o Last shipment of hazardous.waste: Name of Hauler: Destination: WAste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, s age and disposal of 111 gallons or more a month requires a license from the Ppblic Health Division. 1 LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the-Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) 113 Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED -2-3 OwdAny other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Fiammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers QX j 2e.r� 2 (including bleach) 2i v� 13 �ctel Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Hazardous Materials On-Site Inventory/Inspection For ALL Shops and Businesses in the Town of Barnstable : , DBA: ��o� ' QG�c -o C.+d Location: LA (oo Eqx,.-i i L! � Date: - 2-7 Physical Features to Inspect: Hazardous waste generation sites (production/manufacturing areas): Ada Waste storage areas: rvl,q Satellite accumulation points throughout: HazMat stored outdoors - CHECK OUTSIDE: Nb Shipping and receiving areas: jV Run down of shop activities: Housekeeping practices: Aft b -Z7 -ocl 1 ' HazMat On-Site Inventory/Inspection: Records to Review for SQGs and CESQGs DBA: Location: Site visit date: Hazardous Waste Manifests: Employee training documentation (if required): Hazardous substance spill control a9d contingency plan: • . MSDS on site? r HazMat Inventory records (if applicable): v en:d. • HazMat Waste Shipping documentation: . • Spill records (if applicable): �C, i Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS DBA: .Pool N Patio,Ltd. Fax: — Corp Name: Mailing Address ....._........ _. _... _. .....__ _.. Location: 460 Bearses Way,Hyannis Street: P.O.Box 495 mappar: City: N.Chatham Contact: 'Marty Caron State: Ma Telephone: ;(508)778-8727 Zip: 02650 Emergency: (508)255-0416 Person Interviewed: Business Contact Letter Date: 8/20/2004 Category: .Miscellaneous Inventory Site Visit Date: 8/27/2004 _.... .._ �. ._....._._ _.___._._......... Type: 'Retail Follow Up/Inspection Date: 91 public water ❑ indoor floor drains ❑ outdoor surface drains ❑ license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed 0 town sewage ❑ indoor catch basin/drywell ❑ outdoor catch basin/drywell expir -— -- -- ❑ on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: _. ...... _ Swimming pool chlorine,4 Cases Bromine Concentrate,4 Cases compliance: Bromine Tablets Sj C or-k- 5 AN- / I -70 r Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than II I gals ❑ gty's I I I gals or more Waste Transporter: ! Fire District: Last HW.Shipment Date: Waste Hauler Licensed: No COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION Sy0 FEB 0 6 2001 TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 460 Bearses Way,Hyannis,MA Owner's Name: Wiliam P.Swift Owner's Address: P.O.Box 336 Barnstable,MA 02630 Date of Inspection: January 15,2001 Name of Inspector:(please print) Joseph M.Martins Company Name: Accu Sepcheck Mailing Address: 17 Northside Drive,S.Dennis,MA 02660 Telephone Number: 508-385-5891 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs F er Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: / Z3 O 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. Notes and Comments 1. System shows signs of being previously stressed. 2. Maintenance Pumping recommended tank and pit. 3. H-10 Loading Tank and pit. ****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. i Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6$-Bearses Way, Hyannis Owner: Swift Date of Inspection: wilt l Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found anv information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system 'components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Bo f Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following st ents. If"not determined"please explain. The septic tank is metal and over 20 years old* or the se p . tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or ailure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as proved by the Board of Health. *A metal septic tank will pass inspection if it is struc ally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage bac or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a br en,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: e 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: I. i Pale 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: 1/15/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Boar ealth 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 det Ines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner ch will protect public health,safety and the environment: _ Cesspool or privy is within feet of a surface water Cesspool or privy is w' in 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)d�ent: s that the system is functioning in a manner that protects the public health,safety and euviro _ The system has a septic tank and soil absorption system (SAS)and the S 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 withi Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS ' within 50 feet of a private water supply well. _ The system has a septic tank and SAS and t AS is less than 100 feet but 50 feet or more from a private water supply well". Method used to ermine distance "This system passes if the well water alysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic comp ds indicates that the well is free from pollution from that facility and the presence of ammonia nitro and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. copy of the analysis must be attached to this form. 3. Other: I f Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: 1/15/01 D. System Failure Criteria applicable to all systems: You must indicate"yes'or"no"to each of the following for all inspections: Yes No _ _✓Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SA5 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 ,/ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma / 0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinkin er supply the system is within 200 feet of a trib to a surface drinking water supply the system is located in a i ogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public er supply well If you have answer yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Secti above the large system has failed. The owner or operator of any large system considered a signific reat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 . The system owner should contact the appropriate regional of-lice of the Department. Pave 5 of' I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTAhY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: 1/15/01 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 '? t//Have large volumes of water been introduced to the system recently or as part of this inspection ? _A!/A 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,di en ions,de th of ligyid,depth f stud a d depth of scum ? $t-tq T,v O/J� m 4�Pole Gl FVg5-,s ToCP.ilr�°�0�*12iC _✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems" The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no �4xisting 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 CM 15.302(3)(b)] i Pace 6 of' I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS4huwwww"worrION FORM P A kl t SYSTEM INN&ATION Property Address: 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: SS`` *FLOW CON DITIU1 RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 c of bedrooms): Number of current residents.- Does residence have a garbage grinder(yes Is laundry on a separate sewage syst es or no): _ [if yes separate inspection required] Laundry system inspected (ye no): _ �9y�r C�qq 3 31006 5 a/��l Seasonal use: (yes or n — Water meter rea i s, if available(last 2 years usage(gpdT"d000 = ?SOOoJ Sump pu yes or no): _ J/ Las e of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: kOOm Design flow(based on 310 CM 15.203): _gpd Basis of design flow(seats/person s/sgft,etc.): ��`„� a -F TZ OGFiC�� $� 6Pv//a00�ErW)L Grease trap present(yes or no): �j0 Industrial waste holding tank present(yes or no): /V0 Non-sanitary waste discharged to the Title 5 system (yes or no): NQ J n Water meter readings, if available: /cb0� /99o�G00 ;��j� rTUy��, � Last date of occupancy/use:j�O I�'TZ S{fZI(,c�rq�i� OCe <900 0 �C7-'" Or-GIGC OTHER(describe): 3 —0 0 44c pG O �'��22Cv p jete , GENERAL INFORMATION Pumping Records /� ��p IK3 R) f t�M Source of information: /V I'-yo� r Was system pumped as part of the inspection(yes or no): _ 0 If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ZSeptic tank,di ' n ox, soil absorption system .1>&X IJ07— 6,,6. _Single cesspool 0/' loca P� _Overflow cesspool _Privy _Shared system (yes or no)(if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: tmke own Were sewage odors detected when arriving at the site(yes or no): Lv 0 I , Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: — ----- — 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: 1/15/01 BUILDING SEWER(locate on site plan) Depth below grade: A& ' Materials of construction: _cast iron _40 PVC_other(explain): 114knyuM Distance from private water supply well or suction line: _ Comments(on condition ofjoints, venting,evidence of leakage, etc.): ha' y ewo dl a y_pea r fa 6e �s�.�� SEPTIC TANK:_(locate on site plan) Depth below grade: 36 " Material of construction: �oncrete__metal_fiberglass_polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) O X J 7 e2 •1) low pidol Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: .1 0�-/4ed"Sl/r Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Q Distance from bottom of scum to bottom of outlet tee o baffle: L'1C7 f-lnegsV rPa How were dimensions determined: Jyrady � �STIGC �S/�d4v�� Comments(on pumping recommendations, inlet and outlet tee or ba Ie condition, structural integrity, liquid levels as r5ifted to outlet invert,evidence of lea ag etc.): n / rep � a Soli P % __ve-d WrfA mi rror . No Poi �Pd« 4 /�qka�� L/aPviD 11weL q� -'; GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_ot (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom of et tee or baffle: Date of last pumping: Comments(on pumping rec endations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet in evidence of leakage, etc.): Page 8 of" I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 460 Bearses Way, Hyannis Date of Inspection: Swift 1/15/01 TIGHT or HOLDING TANK: (tank must be pumped at time pection)(locate on site plan) Depth below grade: Material of construction: concrete meta fiberglass polyethylene__other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present(yes o Alarm level: Alarm in working order(yes or no): Date of la umping: Com nts(condition of alarm and float switches,etc.): 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.): / .S aNl e I ac`� /. j W ke- . Lo Cali On orf 9 nu�,e, 7yq ns M I+ierr a/0t"Q vS Coy R-+, n D PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): �rQ,SQ/1�. Alarms in working order(yes or no): Comments(note condition of pu amber,condition of pumps and appurtenances,etc.): i Paec 9 of I I OFFICIAL INSPECTION FORM — NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 460 Bearses Way, Hyannis, MA Owner: Swift Date of Inspection: 1/15/2001 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type � 7 leaching pits,number:_t' ` �G q leaching chambers, number: ��T �� ,/ � Q 3•-S, 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.)- " �ret 'n SO�• S. �rn i 2'('oKutPit�P� .�M o r .41 1t 1 Q e e0j NO o0'i r- i 4Pw9/l5 . CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater info es or no): Comments(note conditi soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) , Materials of construction: Dimensions: Depth of solids: ' Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): I Pace 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION .continued) Property Address: — 460 Bearses Way, Hyannis Owner: Swift Date of Inspection: 1/15/01 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. E� s 6 � � w , 1 3.S I'a�c I I of I i OFFICIAL INSI'EC -ION FORM — NOT FOIL VOLUNTARY ASSE:SSME;N'rs SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 460 Bearses Way, Hyannis Owner: _ Swift Date of Inspection: wilt I SITE EXAM Slope Surface water Check cellar Shallow wells q j Estimated depth to ground water _ feet 3. 1 FRS 4,eo� Pff j$70M Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked,date of design plan reviewed: 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) t/Accessed USGS database-explain: " 6 S CQU ift 14fl7'�' You must describe how you established the high ground water elevation: 7v A) nA i a, 0 vs C�r�7�' 45A P., fi ltN 2 3 � i Town of Barnstable � v Regulatory Services S Thomas F. Geiler,Director Public Health Division • Thomas McKean,Director 10 tA 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax. 508-79 6304 Application Fee:$100.00 _ ASSESSORS MAP AND PARCEL NO. DATE r 4 +� APPLICATION.FOR PERMIT.TO.STORE.AND/OR UTILIZE.MORE.THAN. 111.GALLONS.OF.HAZARDOUS MATERIALS FULL NAME OF APPLICANT (Ifczz,)C�a (2(2 CC) 'C NAME OF ESTABLISHMENT -i-C)n t_ (� � _Pa: 1 (5 A- ADDRESS OF ESTABLISHMENT Lea ZSC°_ O-_k ,UAa Dn�� 0.260 , TELEPHONE NUMBER (,5n 2) SOLE OWNER: ". S NO ~ IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK ty _ f SIGNATURE OF APPLICANT -RESTRICTIONS: HOME ADDRESS o `Spin Ct�r:c62 �., �1�¢ry�YY��I.021o(� TELEPHONE#�6$ Rmdodwp/q Apr 10 09 09: 59a FRAME CENTER INC. 781 -762-0870 p. 2 From: 508 760 8998 To:Wayne Petty Date:1112612004 Time:3:49:22 PM Page 2 of 12 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS `4 DEPARTMENT OF ENVIRONMENTAL PROTECTION �k TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Pr•opert"y Address: Owner's Nnmc: . , 4)%t•her4s Address: MO? 1)alc of lnspectiun; Namc of Iospector:(please print) (•omp:iny NArne: DAN A.SPEAKMAN !hailing Address: C011186 Ian 16$peak Way fctcphimc Number: _ Noftll Ham",MA 02M 1.508-432-5565 CERTIFICATION STATEMENT I cerlill that I have personally Inspected the sewage disposal system atthis address and that the information reported 1=clot is true,accurate and complete as of the time of the inspection.The inspection was performed based on my Ir,iinh)g and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP appruwed system inspector pursuant to Section 15.340 of Title S(310 CMR IS.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails i nspeclor's Si. nature: Date: �V 10 I tic.ystcm inspector shall submit a copy of(his inspection report to the Approving Authority(Board oftleahh or 01••r)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10.000 pd ur ,greater,the inspector and the system owner shall submit the report to the appropriate regional office of'the IN:.p.'1 he original should be sent to the system owner and copies sent to the buyer,if applicabie,and the approvink • hority. • Noics and Comments T/C 74-Ofr „J 6-feu—#-'0' S. 1 . •"Phis repurt only describes conditions at the time of inspection and under(he conditions Ouse at that ? time. This inspection doer not address how the system will perform in the future under the same or different • i1. _ t:�rntilirNhs of use, 'I itic S Insl)cCtinn Darin 611 V2000 page I Apr 10 05 09: 58a FRAME CENTER INC. 781 -762-0870 p. 1 FRAME CENTER, INC. 460 Bearses Way Lffomdo HYANNIS, MASSACHUSETTS 02601 LETTER (508) 790-9550 0 (800) 980-9550 �— Date.._..............! ... TO.. .......d...............:. ... Subject. G�P...._........_Q��/fie,f.....�/ ................ /.7 ...... .,�. ............................................................ _.................._.............. .......................................................... ...................... ........................._....................._/.. _. _ .................................................._........_..........................._..........._._.......--- _. ............................................................................................................................................................................................... .............................................................................. -4�. ...... ............ .........?!!� ... ....... .......................................................... .............................. ............................. 't ........ ..............._.�cy.�—...-................ _............................................................._........................._....................._..........................._._..............._._............... .................................................1 .../.......... ri . ............�.: ; .... ..._........, - .:..., k .. .................. ................................ ...... ....../ ........:...... ' ' � ...................................................................:............._...._............. .._......................I. _._........................................ ....._.......... _ .............._..............._................................ _._........................................ ........................................... El Please re I � . .........._........._..............._.........._....................................... .. p y ❑ No reply necessary SIGNED Apr 10 05 03: 59a FRAME CENTER INC. 781 -762-0870 p. 3 From: 508 790 8998 To:Wayne Petty Date:11126/2004 Time:3:49:22 PM Page 3 of 12 II)FIA('11 All. I NSJ11-'(:*V10N FORM—NUFFOR V01XNTARY ASSESSMENTS SUBSURVA(*11",SEWA(4,DISPOSAI,SYSTEM INS)"ll,'(1-10IN FORM PART A ('1";14TIFWATION (cominkiedi A,I1,C,D or F Ak.WAV�cumph:Iv all ot'Sectivii 1) o"llotitil) which illdicalcN that any ofilic Chilurc critchudcscribigi ill.;II)(NIR 'w ill Mlt 1 ;04 uxisi. Ali% 11111tirk!UiICI'nt V0 evOILIDled 01V indicnicd liclow. Pass"section livit:0 In b.:rcplak':!.I ou i': op;tit coiiqi let ill,%i)('I lit:replaccowot or rcpair.ms approved by i lie I loart!of I km It Ii. %%dl pa,,, 0,11 dowminwO(Y,;14.NI))ill the Vor thc !:I lit I kv 1;1,11, 0-111d;1I;)Ilkt 20 Nuors old' or ilic septic will,(wIwthc.r nicial ill not) ioll(1m.1sn orc.\11iltration or lank failure is imminent. �ysicm\%-iti pass in"liccot-ii ii ii)c 1.111L 1,l*eI)I;1L:Cd With ji t:o11lI11%.i1jg Sk:j)(jC tl.tljk -,IS jJI)PPoVed by the 13murd of I Iq11111. 'co:( 1.11A -will paN,itikot:ciioil if it is struciurallysound,not lvakingalltl il'ji of "'1;ipjj:jj)c;. k ha.IN111 '0 wars old is available. of'w\llagc 1xickup or hi-cult ntit or high Matic w4tul'IVvc.t if)Inc"Il.."tribuji(w bk'g Out ill[vt;kc), -I 11111010 0( dtm: to i'. I;-kolevell box.sysmil xviH pa.;.N in pccllol 11"I%%ilh tiff hrokcii pijv(s)arc iclilacc(I uhs1ructiov,is rt:owvcJ diNtrihtilion box is 1C.-VeltA 01'IVpIXCd l"!q'i".c(I 01,11111ing lliorQ than.4 11 yt;;11-due to hiokc-.-Of 0I)SU'LICICif IlilW11). I he !.'.I) I )III approvol Iliqrkl ill,I It:;I101i: broken pilwts)arc rvplacLd )bslrllctiun is rrvioveo 2 Apr 10 05 09: 59a FRAME CENTER INC. 781 -762-0870 p. 4 ,um. Duo twouuts ro:Wayne Petty Dale:11l26/2004 Time:3:49:22 PM Page 4 of 12 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK[ PART A CERTIFICATION(continued) I'roperly Address: _' EAI2SES C_cJj r t lM licl —_ 72'Q DOC ul Inspection: "If,er Evaluation is Required by the Board of Health: *J GP l;tmditions exist which requite further evaluation by the Board of Health in order to determine if the system i�Cailin--W Protect public health,safety or the environment. I. Sy.stem will pass unless Board of Health determines in accordance with 310 CMR 15.303Oxb)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 C'csspool or privy is within 50 Feet of a bordering vegetated wetland or a sail marsh 2. lyalcin will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syslcm is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption tiystem(SAS)and the SAS is within 100 feel of a surface water supply or tributary to a surface water supply,. The system has it septic tank and SAS and the SAS is within a Zone I of a public water supply. Thy system has it septic tank and SAS and the SAS is within 50 feet of a private water,upply wc11. The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a Private water supply wells•. Method used to determine distance [his system passes ifthe well water analysis,performed at a DEP certified laboratory,for coliform baclerin and volatile organic compounds indicates that the well is free from pollution from that facility and [lit: presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no Other lailure criteria are trigpt:red-A copy ofthe analysis must be attached to this form. 3. 0dier: Apr 10 05 09: 59a FRAME CENTER INC. 781 -762-0870 p. 5 rrom: oua!9U 8998 To:Wayne Petty Date:1112612004 Time:3:49:22 PM Page 5 of 12 e OFFICIAL INSPECTION FORM!—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ �f S e-_e Date of Inspection: ii 1 31.bl% D. System Failure Criteria applicable to all systems: 1 oi; must indicate"yes"or"no"to each of the following for ainspections. VCS No c.�ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _,...Discharge or ponding of tMuent to tho aurfaec of the ground or surface waters due to an overloaded or clogged SAS or cesspool ..�atic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �uid depth in cesspool Is less than 6"below invert or available volume Is less than%,day now ,—,*equired pumping more then 4 times in the last year NOT due to clogged or obstructed pipe(s).number uf'(ilnes nun.ped__ �r y 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 surfbce water supply or tributary to a surface water supply. ✓1Cny portion of a cesspool or privy is within a Zone I of a public well. ....zany portion of s cessppol or privy is within 50 feet of a private water supply well. ,,,AI1y 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.IThis system parses it the well water analysis, performed at a OEP certified laboratory,for coliform baeteria and volatile organic compounds indicates that the well to tree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than S ppm,provided that no other failure Criteria are triggered.A copy of the analysis must be attached to this form.1 ^16(Yes/No)The system fI tj�,I have determined that one or more ofthe above failure criteria exist as described in 310 CMR 15.30),therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. I, f,Arge Systems; .1'o be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd, Y ou must indicate either"yes"or"no"to each of the following: f I he criteria apply to large systems in addition to the criteria above) 4l X 11(� the system is within 400 feet of a surface drinking water supply tlic syston is within 200 feel of a tributary to a surface drinking water supply fhe System is located in a nitrogen sensitive area(Interim Wellhead Protection Arta I WPA)or a mapped 4one I of a public water supply well u you have answered"yes"to any question in Section E the system is considered a significant threat,or answered 1_.' ill Section D above the large system has failed.The owner or operator of any large system considered a >Irn;t t aw threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR system owner should contact the appropriate regional office of the Department. Apr 10 05 10: 00a FRAME CENTER INC. 781 -762-0870 p. 6 ov oet,o ro:vvayne Petty Date:11/26/2004 Time:3:49:22 PM Page 6 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM PART 8 CHECKLIST Peopert) Ad(Jress: Owner: I)ilty of inspection: T — t'hc<I if the rollo wing have been done.You must indicate"yes"or"no"as to each of the following: l c% No --l"umping information was provided by the owner,occupant,or Board of Health ,--Orcre any of the system components pumped out in the previous two weeks ✓ I las the System received normal flows in the previous two week period c- dvc large volumes of�water been introduced to the system recently or as part ofthis inspection WWcre as built plans ofrhe system obtained and examined?(If they were not available now as NIA) ✓ Wa,,the facility or dwelling inspected for signs of sewage back up Was the Rile inspected for signs of bfcak out,.' Were all system components,excluding the SAS,located on site t.,� Wcre the septic tank manholes uncovered,opened,and the interior of the tank inspected for the conditinn )l the bafl)cs ur Ices.material ot'consrruetion,dimensions,depth of liquid,depth of sludge and depth of scum Was the Iitciliry owner(and occupants if dift''erent from owner)provided with inrormation on the proper �rr,tiracoance of subsurface sewage disposal systems flw-.,i.e and location of the Soil Absorption System(SAS)on the site has been determined based on: no .+r li...islirtg information.For example,a plan at the Board ofHeefth. �..•+� DercnnimA in the field(if any of the failure criteria related to pars C is at issue approximation of distance r�unacceptable)1310 CMR 15.302(3)(b)) Apr 10 05 10: 00a FRAME CENTER INC. 781 -762-0870 p. 7 "te fvu eaett io:Wayne Petty Date:11/26/2004 Time:3:49:22 PM • Page 7 of 12 Pa.-C 0 o)'I I OFFIC-1AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pruperlly Address:_4!1e_0 Mile o1'Inspection: y / FLOW CONDITIONS Ntmhce of bedrooms(design): _— Number of bedrooms(actual): ui-SKIN How based on 1 to CM'k 15.203(for example: 110 gpd x M of bedrooms): NunrOrrul current residents:____ --""— Uu-s rc�idcnce have a garbase grinder(yes or no):— I:;latimir' rin u separate sewage system(yes or no):_ cif yes separate inspection required) I.uundry system i+lspected(yes or no):--- `c:nnn;tluse:(ye%orno): _ A'alci meter ecadings,il•available(last 2 years usage(gpd)): Sumr htmll>(yes or no):_ _---- 1.,ttit dale ol'occupancy: _ _. COMMt RCIAI.ANDUSTRIAL r I Apr ul'Caablishrtlent PEA ciCe lksmn 110w(based on 310 CMk 15.203):_S12�=_gPd I)aeis of design flow(%LGtsipersons/S4etc.)• i.4/C�5�ft � -gyp �: x�0 pJ�.C1L'F:J�G��do�C•CGG'.j GPO 6 vilsk!tap present(yes or no): xJ0 Indl1su iitl wash:holding tank present(yes or no): AJO Npn.uuiii:u'y waste discharggcd to the Title 5 system(yeS Or no): wa "'mcr mem.-readings,if available: I.om date ol'uccupancyluse: O1-11F.12(describe): GENERAL INFORMATION Pumping,Ftccurds 'tuu'Cc of infnrntation: %:tc;y.1011 pumped as part of-the inspection(yes or no):,!iP w� If%cs. volume pumped: _ -_- Zallons--Pow was quantity pumped determined? Rcm;nu fvr PC)m ping: ._—_... _� ---- I'YPF:OF SYSTEM 1411;c tank,distribution box,soil absorption system Single cesspool pvertlow cesspool Privy .Shared syslend(yeg or no)(if yes.attach previous inspection records,ifany) hmovalivciAlternative techrtolog3%Attach a copy of the current operation and maintenance contract((o be nllt:,inVel li-0111 sy'Slem owner) T;L>hl lank _ Attach a copy of the DC•P approval 'i OIhei (describe): Appfo.\imatc nee ol'all components,dote installed(if known)and source of information: 1�crc agw odors detected when arriving at the site(yes or no):A(1 0 Apr 10 05 10: 00a FRAME CENTER INC. 781 -762-0870 p. 8 ou oaao 1 o:vvayne vetty Date:11/26/2004 Time:3:49:22 PM r Page 6 of 12 l';1sc 'r of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'Yf:O 2W4q ;'S5SGu9>el Owner: - U»tr of lospectinn: ii 7— �c, 11kII1,1)IN(i SEWER(locate on site plan) I h p111(i.I+>w rade:(>Ad 2 S'ol$ Materials ul-construction:---cast iron _40 PVC_other(explain): y Distiv,ce Born private water supply well or suction line: (omnlcnts(un condition of joints,venting,evidence of lea—kage,etc,); �sf'T IC TANK:_ Iodate on site plan) If A I)�plh below rude:. rt_ _I• "_OV46't + t9� ArJ/C. T5, 4 4019 Material of construction: t,,,�:eite e—metal_fiberglass polyethylene Ulherlexplain) ___ ' 1 I'1:11)k is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of cclYilicate) I)intt:nsipn�: Sludgy:depth _......._.._ ._._ t)iytancc from top of siudge to bottom of outict tee or baffle: titunllhickncss: _ {)1s1:u,Ce frutn tt+p of scum to top of outlet tec or baffe:_L© _J 1)klance I'R?m bottom of scum to bottom of outlet tee or baffle: -- I low were dimensions determined: /47ff1 ( 11111 111s(o)pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels ct.r related to outlet invert,evidence of leakage,etc.): AJ C) .�_C.4 jf-s-7-0 iO-JL.0 r 09 eau; CREASE TRAP,(locatc on site plan) l)cpilt below(trade. Mittcrial o1'construe6pn: _.concrete metal_.fiberglass polyethylene__other — SC11111 thickness t h9W11ce Imnt top of'scum to lop of outlet tee or baffle: I)iaaulce Pram bottom ot'scurn to bottom of outlet tee or baffle: Date of last Pumpillb:__...—_.._. t-uruncnts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels its i-el:ucd to pullet invert,evidence of leakage,etc.): :u., t 1,.,•......: r. ...Nn ci�nnn 7 Apr 10 05 10: 01a FRAME CENTER INC. 781 -762-0870 p. 9 MITI: 508 790 8998 To:Wayne Petty I • Date:11/26/2004 Time:3:49:22 PM Page 9 of 12 I'a�c n of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P,-opc'rh'Address.- Owner: pale of Inspection; '11CHT ur HOLDING TANK:/U00(tank must be pumped at time of inspection)(locate on site plan) l.lcplli below grade: _-- Morin ial vl'construction: —_ concrete -metal_fiberglass__polyethylene_othef(explain): Dimensions: - — - 1 cy!ac i iy:...... alloos Ihsipn flow; _ _ _ ^_sallonsiday iUarm present(yes or no): -- Al,omlevcl: __ Aldrinin working order(yes orno): Dale of last pumping:__ l:ummcnts(condition of alarm and Float switches,etc.): MSI'RIBUTION BOX:,09(ifpresent must be opened)(locate on site plat) Dcplh of liquid level above outlet invert:_ (:ummcnls(ante if box is level and distribution to outlets equal,any evidence of solids Carryover,any evidence of Icakage into or out of box.e(c.): Pt IN1P 01AMBER,114(locate on site plan) Pumps in working order(yes or no): T A larms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances.etc,): Apr 10 05 10: 01a FRAME CENTER INC. 781 -762-0870 p. 10 From: 508 790 8998 To:Wayne Petty Date:11126/2004 Time:3:49:22 PM � Page 10 of 12 Paee oi-I I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ��// SYSTEM INFORMATION(continued) I'voppertyAddre9S: 7�Oa '�..A- k rCSce 9% - 1)wit:ul'Inshcclion: SOf i,AKSORPTION SYSTEM(SAS): `Tlocate on site plan,excavation not required) It SAS nut located explain why: &—le-itching pits,number leaching chambers,number: leaching galleries,number: teaching trenches.number,length: Icac•hing fields, number,dimensions: uvrrlluw ccsspooh number: _ innuv8livc/allernativt system Type/name of technology: CK ):in�:nt5(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, cic.):� to r� r�,•,.G _ T �Yf .......�.�. -^ vt r=os•e••,•,.U.�._ �� e..�o�,v C. .J 0 Pff7?-9 7-IV J CESSPOOLS:�UF(cesspool must be Pumped as pan.of inspectionxlocate on site plan) Nunihcr and configuration:_ fA•p(lt top of liquid to inlet invert:T Uclnh ofsolids layer: Dopih ol'scum layer: - Uinwnsions oftesspooi; _- �ldotcri;lkofconstruction: __-- — Indicalirnt of groundwater inFlow(Yes or no): — Cuntrnenis(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,tic.): 1441IVY: (locale on site plan) klmerialc ol'construction_ I)imemionsc --- I)Cpth -- ('o�miicntu(note condition of suit,signs of hydraulic failure.level of ponding,condition of vegetation,etc.): Apr 10 05 10: 01a FRAME CENTER INC. 781 -762-0870 p. 11 4vo iau onaa io:Wayne Petty Date:11/26/2004 Time:3:49:22 PM e Page 11 of 12 1'ugr I p pl'1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM PART C SVSTEM INFORMATION(continued) I1roperll Address; Owner; p 014te of Inspection: i SKI raI OF SEWAGE DISPOSALSVS'IrEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or hrnch'na'f s. "cate all wells within 100 feet.Locate where public water supply enters the building. .—.. � .—Zoo �5/60 l c;Wo Y� z. 26 y8s r..,.. c .., c,. _.a cnnnn 10 Apr 10 05 10: 01a FRAME CENTER INC. 781 -762-0870 p. 12 From: Sob 790 8998 To:Wayne Petty Dale:11/26/2004 Time:3.49:22 PM Page 12 of 12 Pave I l of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- Z46-4 1 =3 O+vncr: 4 7? Date for Inspection;ee,",,z 4zo SII*E EXAM Slope 111i(lcc wafer Check cellar I Shallow wells kstimawd depth to ground water feet C?le0 X n77M ate' e",' 11I.:a;c indicate(check)all methods used to determine the high ground water elevation: 0bluined from system design plans on record.If checked.date of design plan reviewed: _. Observed site(abutting propertylobservation hole within ISO foot of SAS) Checked with local Board of Health-explain: (:pecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: C4iGLL 3a JD yr c-µ4 .7 ►�^ � S �-i" �Z, 2 a