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HomeMy WebLinkAbout0014 BUMPUS ROAD - Health 14 Bumpus Road,Hyannis A=.. 3/0._ a RE'YCLFOC UPC 17734 No 0b37dON HASTINGS. MN 1 F 2-0 t-, o� -7 -7 az r ,S �/> �v�4y77p �ti /t Cv " ?mac. zv C r i .. 310- 03' Commonwealth of Massachusetts - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a °M 14 Bumpas Road ` Property Address William Goodman Owner Owner's Name M. information is ✓ required for every Hyannis Ma 02601 4-27-18 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. filling out forms A. General Information �'� - I col(a filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 _ Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-27-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or_E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in passing condition at time of inspection and the tank was pumped for maintenance after the inspection was complete. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �nM 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ . ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 14 Bumpas Road M Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): No design Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Bumpas Road Property Address William Goodman. Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): See below Detail 2016-72,556gallons 2017-67,320gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27718 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date. Other(describe below): General Information Pumping Records: Source of information: Pumper driver- Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank size Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade. 28 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every �H annis Ma 02601 4-27-18 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped for maintenance after the inspection. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA � Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No . Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every y H annis Ma 02601 4-27-18 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. PumpI Chamber(locate on site plan). Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA " If pumps or alarms are not in working order, system is a conditional pass, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis, Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ 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.): Leaching was in passing condition at time of inspection. The pit had standing water 16" below the invert. Pit was more than 3/full when viewed. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR A B 2 Al-23' 81-25' A2-33' B2-15' A3-45' 133.22' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is Hyannis Ma 02601 4-27-18 required for every y , page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 12' 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: A hand.hole was augured to 12' with no ground water encountered. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water,elevation:. A hand hole was used to determine that groundwater was >12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpas Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis annis Ma 02601 4-27-18 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Mp 14 Bumpus Road tQ" Property Address tl William Goodman Owner Owner's Name/ r l information is �/ required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection t � �w1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company � Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-18-15 Inspector's S ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 4� S t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposa ystem•Page 1 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection, Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is req u i red fo r eve ry Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: No Number of bedrooms(design): plans sign Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gp ))� Detail: "READING ATTACHED" Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 `Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumper driver Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank size Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 28" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): 16" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon i 811 Sludge depth: t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle - 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal to outlet invert. Tank was pumped for maintenance after inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 : Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil_ Absorption System (SAS) (locate on site plan, excavation not required): :t located exp lain lain wh If SAS o P Y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is Hyannis Ma 02601 8-18-15 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6'x6' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. The pit was 2/3 full when inspected. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 : Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately RQox A A, 6 O IA2 3 y S B3 . 22' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high groundwater: No Gw 12' 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: Previous inspection where hand hole was augered to 12'with no sign of water ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Records at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 14 Bumpus Road Property Address William Goodman Owner Owner's Name information is required for every Hyannis Ma 02601 8-18-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Date: 8/19/2015 Customer# 6063934 f Meter Readinn History Page 1 o Premise#696393 Service:Water-Regular Metered METER READING. ReadTRANSACTION INFO ¢ate Meter# Face Sort # Bead Code Readlna CqUag IXI? Code > BIN Period 05/12/2016 01 93530921 0 27010490 1 189 12 0 REG A R 02/04/2016 01 93530921 0 27010490 1 201502 05/19/2015 177 8 0 REG A R 201501 02/12/2015 11/10/2014 01 93530921 0 27010490 1 169 33 0 REG A R 08/15/2014 01 93530021 0 27010490 201404 11/16/2014 1 136 60 0 REG A R 201403 09/0312014 02/1 02/12/2014 01 93530921 0 27010490 1 76 15 0 REG A R 2/2014 01 93530921 0 27010490 201402 05115l2014 1 61 10 0 REG A R 201.401 02/19/2014 11/11/2013 01 93530921 0 27010490 1 51 19 0 REG A R 08/13/2013 01 93530921 0 27010490 201304 11/21/2013 1 32 32 0 REG A R 201303 08/23/2013 05/30/2013 01 30288770 0 27010490 t 2,308 0 0 REG A O 05/3012013 01 93530921 0 27010490 201303 OS/302013 0 0 0 REG A S 201303 05/30/2013 05/09/2013 01 30288770 0 27010490 1 2,308 21 0 REG A R 02/12/2013 01 30288770 0 27010490 1 2,287 16 6 20130 0 /2013 REG A R 201301 02/202l20/2013 11/13/2011 01 30268770 0 27010490 1 2,271 13 0 REG A R W14/2012 01 30288770 0 27010490 1 2,258 32 0 REG q R 201204 11/25/2012 05/15/2012 01 30288"0 0 27010490 r 201203 08/21/2012 2+226 8 0 REG A R 201202 05/24/2012 02/14/2012 01 30288770 0 27010490 4 2,318 7 0 REG A R 201201 02/23/2012 1 01 10288770 0 270104� 1 2,211 16 0 REG A R 201104 11/22/2011 08/15/15/2011/2011 01 30288770 0 27010496 1 2,195 33 0 REG A R 201103 08/23/2011 05/17/2011 01 30288770 0 27010400 1 2,162 0 0 REG E R 201102 06/OTJ2011 02/15/2011 01 30288770 0 27010490 2,162 9 0 REG A R 201101 02/28i2011 11/10/2010 01 30288770 0 27010490 1 2,153 14 08/19/2010 01 30288770 0 27010490 0 REG A R 201004 11/22/2010 1 2,139 14 0 REG A R 201003 09/02/2010 05/1812010 01 30288770 0 27010490 1 2,125 0 0 REG A R 20t002 05/27/2010 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address I / A� �)arl� �GtG�aSS Owner Owner's Name information is required for A every page. City/Town 01 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: ��//� // /✓/� , only the tab key to move your cursor-do not Name of Inspector use the return /O key . Ij/Y Company Name�� Company Address ,EA 6'J4 4 w, City/Town State Zip Code ��9) Telephone N er License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function andamaintenartce o site sewage disposal systems. I am a DEP approved system inspector pursuarrt�'�to Section 15. .�,0 of Title 5 (310 CMR 15.000). The system: _`' u-rt w s 7 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority s Ins ctors ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. �J/l t5ins•09ioe Title 5 Official inspection Form:Subsurface Sewage posal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments; / P-1 Property Address Owner Owner's Name information is � 671 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /Ll oNrWNS 14 / uv� Property Address / 1 G1 G�osf Owner Owner's Name , information is Qo1601 required for R N✓I1 f every page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �ti GroIS' Owner Owner's Name information is A4 cv 6 p/ 2 11 Ap required for L1 �f7 r f every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow urns•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 o1 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d64 Property Address -Z Ci Clo ff Owner Owner's Name i / information is �,JU �f� required for A✓J✓/ every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or ❑ �bstructed pipe(s). Number of times pumped; ny portion of the SAS, cesspool or privy is below high ground water elevation. ❑ L�" Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 5;--'----Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q/Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ P�' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ �� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ �� The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins-09/08 Tice 5 official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ��GrO is Owner Owner's Name information is Oat 60/ required for /7 r'1 n n iI every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Q� 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 u available note as N/A) Q/ ❑ Was the facility or dwelling inspected for signs of sewage back up? []�❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? [�❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3.362 93 l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments gt4� 14 r Property Address �G Gro,s Owner Owner's Name information is Ay 0.�6o/ required for every page. City/To State Zip Code Date of Inspection D. System Information Description: /0vo 6� Ati 5;wh c- 7-n 4, 121 Number of current residents: Does residence have a garbage grinder? ❑ Yes l' rvo Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ©-'No Laundry system inspected? ❑ Yes t��, —o Seasonal use? El Yes Irk rvo Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-0908 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r Property Address �CrroSf Owner Owner's Name information is y A4 0.)(,0/ required for G► every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: / L i..rr/�C o cif" ���"t.c Source of information: Was system pumped as part of the inspection? Yes ❑ No 1 00o If yes, volume pumped: gallons How was quantity pumped determined? �PC- Reason for pumping: Type of S tem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins,M08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: /913- Were sewage odors detected when arriving at the site? ❑ Yes ryo Building Sewer(locate on site plan): Depth below grade: feet Material of construction: cast iron 2<0 PVC ❑ other(explain): � Distance from private water supply well or suction line: feet A Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1 �� Depth below grade: feet r Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: SX Sludge depth: t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name �� information isL Qo760% 7'—// ^� required for &604#11f" every page. City/Town 01 state Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 0/ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle A How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 41c- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 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 i t5ins-osioa Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l / ✓`1 N I �G Property Address � c�oss Owner Owner's Name information is required for l^NHrj State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•0"8 ritle 5 Official Inspection form:Subsurface Sewage Disposal System•Pape 11 of 17 Commonwealth of Massachusetts kvTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l d, led Property Address Owner Owner's Name information is / J �/1O required for too ' / �Gi✓t 11 every page. Cityrrown State Zip Code Date of Iq pe t'on D. System Information (cont.) Distribution Box (if present must be opened) (locate on sitelan): 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.): so X d S I 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `.. IZ4 914�W,4j- �ci Property Address Owner Owners Name , information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �/e— �,,ff- ©�71�0-1 , �- Type' w leaching pits number: (� ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �� Coy✓ ! rrve. f I .S Ks &7je::'- h C4" 11r-' 7�r /tip 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 t5ins•OWN Title 5 Official Inspection Form-Subsurface Sewage Disposal system-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments Property Address G C�osl Owner Owner's Name information is hr f �i9 QoZ 6 O/ required for A/11 e�j W7 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation, etc.): I Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments note condition of soil, signs of iydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•OW8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t / T �c.+✓�I�OKI J Property Address / .La►GioS�' Owner Owners Name �� information is i/ / OoZ(:,0/ required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where ublic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I l.J If 191-- ,),3 �. d Sins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page IS of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Gt C/'OSS' Owner Owner's Name information is kin/ //�//� o�6 required for every page. City/Town Cle State Zip Code Date of Inspection D. System Information (cont.) Site Exam: /L ❑ Check Slope ❑ Surface water �� a ❑ Check cellar (0-4� ❑ Shallow wells i Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: `0 C c-4-e �, �io f7�/yt ,/�a//!f l h d t�..Ttm L ✓� 7� Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•09/08 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address �i �loSf Owner Owner's Name information is required for u / G ✓f✓7!f 60/ ✓ —���d every page. City/Town State Zip Code Date of inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked [Inspection Summary D (System Failure Criteria Applicable to All Systems)completed [�<Ystem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I 15ins•os(oe Tale 6 Olfidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 C.-Se 0 NAME FFENDER - ,�;;,;,� "ram/ c� - BAR 7 4 TOWN OF 'ADDREF;QFi.E? p4W'.•� it.�++ „✓..j „ U�I:$7 - ;r �C�C�s .. PITY. OAT �TATE, CQQ _ '^ E,O BI TH OF OFFE DEB' BARNSTABLE p� t . �tNE► - MV OPERATOfl LICENSE.NUMBER - MV/MB REGISTRATION'NUMBER • IAS . O.F�F�VENSE 4ANSI E�I .AI1 a�l• -:� �n Vry4).� �pF..�fo �: L6 ,. � �a79• �� '111g�! t� . :. Yam. ,rZ c /.� �t .. /� � %-4.C f�b�,+3��i:���4' 1� � 1 �.f A f y 1?l.� s j... TIME AND DATE OF VIOLATIO ".h L CATION 0 VIOLATION UJI NOTICE OF = ae L� jQA.M:hPM.)ON'; � : ,20t . '+-� c3Z SIGNATUR F ENFORCING PERSON 1 E FORCING DEPT; BADGE NO, W VIOLATION is �l+fit S��rar:f� N 0 OF TOWN I H EBY ACKNOWLEDGERECEIP7 OF CITATION XUJ ORDLNANCE ri Unable tD obtainnig ta4�e o offender THE NONCRIMINAL FINE FOR THIS,OFFENSE,IS: a ° Date•mailed.. 6 �" w OR a r ! YOU HAVE THE FOLLOWING;AALTERNATIVES WITH REGARD TO OISPOSITION.OF THIS MATTER.•EITHER OPTION.(1)OR OPTION(2)WILL OPERATE ASA FINAL 1 her by appearin to person between 8.30 A,M.end 4:00 P.M.,Monde through Friday,leg IL REGULATION .DISPOSITION WITH,NO RESULTING CRIMINAL RECORD," g y rn ( )You may sienna pay Clerk,love fine,sit Hyannis,MA 02601;or mallin a;check,money.orderor postal oats to Barnstable CleroklldPeyeBxcep 0, before The Barnstable Clerk,200 Main Street;H y g OO 22 k Hyannis_MA 02601,_WITHIIy TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE, o. ._. {2)lf.you desire to contest this matter in a noncriminal proceeding you mayy do so by making'wrltten reqquest to DISTRICT,COURT DEPARTMENT,FIRST RNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA'02630,Attn:21 D Noncriminal citation for!a,hearing. Heerings.arid;encloae a copy,of this _ (3),Ifyo6 fail to pay the above;offense.or to request a hearing within 21 clays or if you foil to appear for.the heanng or.to pay any fine determined at the hearing to.be due,criminal complaint may be Issued against you. - ❑ I.HEREBY ELECT the first option above,confess.to.the offense charged and enclose payment In the amount of$ a Signature D Ln �. • 'o i, o OFFICIAL USE:�J l� Postage $ru M Certified Fee nn o a ReturnReceipt Fee PosVgrk'J� D O (Endorsement Required) Restricted Delivery Fee 0 (Endorsement Required) m 09Zp d� r U Total Postage&Fees m Sent co -\C-k-kA Rao C rL 0 v S ------------------------------------------------------------------------- C3 Streef,Apt.No.; / L or PO Box No. SD ,T 1&,f z- 604E - I(0 01 City---- ,ZIP------------------------ rr. Certified Mail Provides: o A mailing receipt - - n A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is notavailable for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the. fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 SECTIONSENDER:,COMPLqTE THIS SECTION COMPLETE THIS ON DELIVERY E. Complete items 1,2,and 3.Also complete Signatu item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Recei ed by(Anted Name) C D e of Delivery ■ Attach this card to the back of the mailpiece, 1 l q or'on'the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: • ' ; If YES,enter delivery address below: ❑No R't e— HA po vte I 3. Spice Type $.pertified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service/abeq d !t?40 8') 3,230 0 0�0 23 t 51 Ali 0 9.0 5 i I I PS Form 3811,February 2004 Domestic Return Receipt" 102595-02-M-1540 UNITED STATES POSTAL,. I i ilst-Class Mail U , • Sender: Please print your name, address, and-21PT In t Is ~ox E I Town of Barnstable 4 I' Health Division F 200 Main Street 5 Hyannis,MA 02601 f4311 ilYi ti13!! } 11 1H i1P11.I-i ii! �Sf17 1 1 Op SHE Tp� Town of Barnstable Barnstable Regulatory Services Department ADAnwfiCaC I �- BARNS-r.►n�E, D "Ass. Public Health Division ArIF MAI a, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 7008 3230 0002 5178 0905 December 9, 2009 Richard Lacross 8065 Tiger Cove-Unit 1607 Naples Fl 34113 EMERGENCY CONDEMNATION Finding of Unfitness for Human Habitation and Determination of Immediate Danger In accordance with M.G.L. c.111, sec. 127A and 127B, 105 CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter II: Minimum Standards of Fitness for Human Habitation, Jaime A. Cabot, R.S., Health Inspector for the Town of Barnstable, on December 8, 2009 conducted an investigation of a dwelling located at 14 Bumpus Road, Hyannis. The owner of this dwelling is Richard Lacross. Based on the results of that investigation, the Barnstable Health Department finds that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D), the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. Conditions found within the dwelling,which give rise to the emergency finding of unfitness and determination of immediate danger, include: 410. 750: Conditions Deemed to Endanger or Impair Health or Safety 410.750 (A) Failure to provide potable water in accordance with 410.180. 410.750 (B) Failure to provide heat in accordance with 105 CMR 410.200. Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated she may be forcibly removed by the local Board of Health (Massachusetts General Laws C. 127B), or by local police authorities at request of the Board of Health. Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from $10-$500. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this unit may not be occupied without the written approval of the Board of Health. Any person needing access to the inside of the dwelling must get permission from the Board of Health prior to entry. Note: This is an important legal document. It may affect your rights. 4TPmaER ORD T ER BOARD OF HEALTH os A. McKean, CHO\RS Director of Public Health Town of Barnstable Cc: Tom Perry, Building Commissioner IKE Town of Barnstable Barnstable Regulatory Services Department AWAmicaCft 4*,11AktNS"CABLE, k9 MASS. Public Health Division V. 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO March 19, 2009 Barnstable District Court Clerk's Office P.O. Box 427 Barnstable, MA 02536 Re: Richard P. LaCross 8065 Tiger Cove—Unit 1607 Naples F134113 BAR#79989 To Whom It May Concern: On December 2, 2008 in response to a complaint I inspected the property at 14 Bumpus Road, Hyannis. At the property I observed violations of Board of Health Regulations Chapter 353-1 Nuisance Violations garbage,rubbish, debris was observed in the yard not in approved containers. An Order Letter from the Board of Health was issued to Mr. Lacross instructing him to properly store the garbage, rubbish and debris at 14 Bumpus Rd., Hyannis. The property was inspected again on December 241h, 2008 unsanitary conditions were observed consisting of multiple bags of household rubbish and garbage not properly stored. A citation BAR#79989 was issued to Richard P. LaCross for violation of Board of Health Regulations Chapter 353-1 Nuisances: Storage of Garbage and Rubbish. Respectfully Submitted, Jaime A. Cabot,R.S. Health Inspector Public Health Division Town of Barnstable Message Page 1 of 1 Cabot, Jaime From: Wadlington, Ellen Sent: Tuesday, December 08, 2009 9:14 AM To: Cabot, Jaime Subject: FW: Address of Alleged Violations/next door neighbor Ellen wall Mall -----Original Message----- From: McKean, Thomas On Behalf Of Health Sent: Thursday, December 03, 2009 8:11 AM To: Wadlington, Ellen Subject: Address of Alleged Violations/next door neighbor -----Original Message----- From: Allison/Larry [mailto:ptlab@hvc.rr.com] Sent: Wednesday, December 02, 2009 7:24 AM To: Health Subject: Re: next door neighbor This is a copy of an e-mail I sent to Ellen this morning regarding the house next door to my parents. Thank you for your help. My parent's address is 28 Bumpus Road, Hyannis. I haven't noticed the number next door, it may be 14 (not sure). Coming from Bearses Way, it is the 2nd house on the left counting the house on the corner, and my parent's house is the 3rd (red) on the left. Let me know how you make out. Thanks again. Allison ----- Original Message----- -----Original Message----- From: Allison/Larry [mailto:ptlab@hvc.rr.com] Sent: Monday, November 30, 2009 6:37 PM To: Health Subject: next door neighbor To whom it may concern, I am writing in regards to the house next door to my parent's house in Hyannis. My parents no longer live in their house because my father has since died and my mother is in assisted living in Hyannis. Due to the condition of the house next door and past tenants' behavior, my parent's house is now a target of burglars, as recent as last week. My brothers and sisters and I are trying to clean it out to put it on the market. The house next door has a broken front picture d window, broken side door, the detached garage is ready to fall down and is used for drug deals, and homeless people have been seen coming in and out of the house. The police are all too familiar with this house and the problems associated in the neighborhood with this house. The other neighbors are concerned as well and something needs to be done; boarded+ up/condemned,contact the owner(lives in Florida and doesn't care)to sell it, etc. Are you the correct department that can help us? Please respond at the e-mail below and let me know. If so, I will give you the address and other details you need. If not, please tell me who to contact next. Thank you for you time. Sincerely, Allison Launhardt ptlab(c-)hvc.rr.com ps i tried to contact you by e-mail earlier, but my work e-mail had a fit and I'm not sure if it was officially sent. I apologize if this is a repeat. 12/8/2009 I FORM30 C&W HOBBS&WARREN T" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A2N ST�g�iE CITY/TOWN a DEPARTMENT U U M t;k_ A tit*-k 1�M ac, ADDRE S (s �)0 t56Z— 4� GSM SvOy`eW /A vb- TELEPHONE Address_ IIA1 A-H ��I �1� Occupant_.\/A C AO- Floor Apartment No. — No.of Occupants No.of Habitable Rooms_No.Sleeping Rooms-- No. dwelling or rooming units \No.Stories Name and address of owner P_� c.%,AAxo LA C V2n SS 8 4,6' (,f-d- U N tZ IWI W APUFs JZ�I- 3 q II Remarks Reg. Vio. YARD Out Bld s.: Fences: So-t-4 e� 1 -} DEE V^ Garbage and Rubbish 9SN % 9 Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.:, ❑ B ❑ F ❑ M Doors,Windows: L i,./ I 0 6v,-\ rk t-i %v�3 o pw Roof V-0 K@r1J "TCNIfN I flop 2 Gutters, Drains: �Zo 4rer.1 Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: - o S e, 15 V NC,c+N Z N 0 w n'tE42 ® ,064.) Dampness: Cal—I fc. cr — -750((,) Stairs: -T _ ps¢-0 to V Li htin : g STRUCTURE INT. Hall,Stairwa - S Obst'n.: 1 Hall, Floor,Wall,Ceiling: 'j r j "v.1ttuLA. ,`, L0 1 Hall Lighting: / Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents:. PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n.- General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJU ' INSPECTOR z TITLE :MtN S �Zo Q- A DATE Z � ZU o TIME 2,210 P.M. A.M. THE NEXT SCHEDULED REINSPECTION 7TA P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts-Department of Public - Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. • TOWN OF BARNSTABLE -Tow LOCATION C 41 * 8 0104 Pv 4 Pet , *tl SEWAGE: VILLAGE A ASSESSOR'S MAP Cz LOT j 6. .INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY /®&o 6-At �ortK o i LEACHING FACILITY:(type) /' / (size) 14 000 A L NO. OF BEDROOMS PRIVATE WELL OR UBLIC WAT BUILDER OR OWNER 1A Crms'S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: "' 1" 7 S VARIANCE GRANTED: Yes No 1 c•► SU O ,. '� f •_ � v ;� li . � �. '; rt r � � J+ . .. � V �: � � . � � '� .� .. • � f jr _ t, _ '.. _.. c� Vic.e jo- THE COMMONWEALTH OF MASSACHUSETTS APRROVED BOAR® OF HEALTH Oarnmwe Cwwrvatien Qvartnont TOWN OF BA R NSTA B LE Application is hereby made for a Permit to.Construct. ( ) oor Repair (i/j"'aan Individual Sewage Disposal System at .........ZY....... ....,3 ..... � ' 1 ------------------------•----- N...---------------------------------------- Location ddress or Lot No. n ....... i 4l.C. 1A L 5's...---..... s�J.`!!3'........................................._..... �a Owner _" � Addres W �4t2�1� ------------------------------------------------ v mac'? ` = y li1?. k24.... Installer Address Type of Building Size Lot................------------ Sq. feet U Dwelling No. of Bedrooms___...._�-, g— _______________________________Expansion Attic ( ) Garbage Grander ( ) Other—Type e of Building No. of persons............................ Showers 0.r YP g --•-----•-----•------•..---- P ( ) — Cafeteria ( ) Other fixtures ------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x s Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. k� Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. TZ, ;Other Distribution box ( ) Dosing tank ( ) 'r " =;Percolation Test Results Performed by.............................................................•---•••••--- Date........................................ '� `` Test Pit No+1 1 _.minutes per inch Depth of Test Pit.................... Depth to ground water........................ 'W -Test�PitrNo 2 minutes per inch Depth of.Test Pit.................... Depth to ground water........................ K;K �"tt a .................................. .• - .... ............................................................................................................. x, fDescription,of'Soil .. •--...-•----------•---•-------•----------------•---•--•------•-----•------•----•••-------•---•......--•-• ----•-• - U •---- -------------•---•---------------•------------------------------------------------------------•---........................................... < � W" r ... y _.__ ................................................................... ..___...........___......._........................_..... . x N ture of.Re airs or Alterations—Answer when a hcabie______._ _. I/ i i �0 �x ► I ...�. ..f+??_dry ° o ------•----•-------•----------------------------------•---- y - af, Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with " », the-provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the �fJ' system in operation until a Certificate of Compliance s been is )ed by the board of health. C• ,r _ t. Signed ------- --------------- ----- 14 t C ta;;.�'Application Approved B -- ...y --.- ..- 1 ,Application Disapproved for the following reaso - .............................................................--------.......--------------- --------- .------.------------... i ---- ----------- -------- ........../ ... . ...........- ............- --......................................... '�n .. - ,.,.•. _ Date Permit No. 4 � ........ .-...--_ - - Issued l7J .... ---—..... ...��................ No.._ � -----._ ( .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Works Tonstrurtiott rnmit Application is hereby made for a Permit to Construct ( ) or Repair (wl"an Individual Sewage Disposal System at: C7 ................____ __.......................................... .......... ..... ...__..... _ ------------------------------------------_-----__-_- �} Location- fddress or Lot No. ,Q / Owner Addressf — 4.. ) a�v........ / .....� 7�.......Z4 •:__/�11 �0 v -----.-----• � il._.. Installer Address Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms--------2-----------_-----••----•---•Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building • ( ) a yp g ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. G� Septic Tank—Liquid'capacity.._.....__..gallons Length................ Width................ Diameter__._--_-__--_-- Depth------_--------. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date---------------------------------------- 0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_•••______---_----.-_. 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water._-_---.._---__•-------. P4 -••-----••--•-••-------------•--••-•-•-••---•------•-•••--------•-••-------......---•-----•--------.......................................................... .o Description of Soil...............................................................................---------------------------------------------------------------------------------------- x c, w N tore of Re.------------------------------------------------------------------------------------------- -------------------------------------------------------------------------,------- U pairs or Alterations—Answer when applicable_.-_-_-- �'tSf ��_....__ aQd----- -_----- -e,)1 �_�___ --------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issbed by the board of health. Si ned ---------- -------- n ------5 yi 9 g _ Application Approved BY --- ��2 / � � j ': —V t'--'�--;�—'------------ .....��_ Dare� Application Disapproved for the following reaso. /-----------------......................-------------------------------------------------------------------------------------------- ........................................ ---......... --------- - ---------------- ------------------------------------------ -- --------------------------------- - Permit No. �• /., - Issued `T 1 sore i te' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 01rdifirak of 01untyitnnxe THIS IS TO CERTIFY, T at the Individual Sewage Disposal System constructed ( ) or Repaired ( 1/) by �� .....! ---..------�,•9C....--�-----------........................................................... I taller at . �... .� . U_j--------------�. .:...........--------.... /f1 /l s has been installed in accordance with the provisions of"TITLE 5 qfe Stat nvironmental Code as described in the application for Disposal Works Construction Permit No. ----"�.... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... ....r. I..'.../".3......................................-------- Inspector --------------- ---------•----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i TOWN OF BARNSTABLE No.......ti_........... FEE............ .... Disposal Narks Tlam r iou rrutit Permission is hereby granted........ ;!..;3............z',q��c_�?........................... --------------------------------•.....•••.....__._.. to Construct ( ) or Repair (-�,) an Individual Sewage Disposal System as shown on the applicatio for isposal Works Construction P r It No.. ..� _.....,...__ Dated___._. 1 9 _v...... .___ g_.. Board of Hfealih I DATE..........................7.................................................... FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS