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Home My WebLink About0255 COMPASS CIRCLE - Health 255 COMPASS-GI , HYANNIS i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle Y Property Address Donald Prouty i r Owner Owner's Name information is Hyannis ,' Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection v1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information <3' P S7� on the computer, Brett Hickey Q use only the tab J key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 cd Company Address, Sandwich Ma 02563 City/Town State Zip Code ,ate, (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey �e �,.,.o.a.m„.��a��..,o..�.-�s 6-6-19 `'bzt.:mie.os.m oess:.xi-aan 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 C Commonwealth of Massachusetts �n Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle V� Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: FE-1 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 working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle V� Property Address Donald Prouty. Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' '•M 255 Compass Circle LJ� Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has.a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El 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 'h day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ rX-1 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ R 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a 9 Y Y Y design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IF' 255 Compass Circle v Property Address Donald Prouty Owner Owner's Name j information is Hyannis Ma 02601 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coot.) If you have answered"yes"to an question in Section C.5 the system is considered a significant Y Y any Y 9 threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C,5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ n 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? n ❑ Was the site inspected for signs of break out? ED ❑ Were all system components, excluding the SAS, located on site? E ❑ 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? ❑ a 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 stem Absorption S SAS on the site has p Y (SAS) been determined based on: El ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 349/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes G1 No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes [R No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: ***2018- 4,000gallons 2017- 3,400gallons*** Sump pump? ❑ Yes ❑® No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 it c Commonwealth of Massachusetts �n Title 5 official Inspection Form �= I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped April 2019 Was system pumped as part of the inspection? ❑ Yes ❑® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle u- Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest -inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New SAS added to existing tank in 2015 Were sewage odors detected when arriving at the site? ❑ Yes 101 No 5. Building Sewer(locate on site plan): 1 rgrr Depth below grade: feet Material of construction: ❑ cast iron ❑® 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle u Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 6. Septic Tank(locate on site plan): 811 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 1 Dimensions: 000gallons Oro Sludge depth: 3611 Distance from top of sludge to bottom of outlet tee or baffle 411 Scum thickness 511 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle �u= Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle u— Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form + I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle V Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers M leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chamber were dry when viewed. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑Q hand-sketch in the area below ❑ drawing attached separately TOWN.OF RARNSTXBLE LOCA1,16x VUXACrE /Sri '✓"'�'r-r _ASSESSOR'SMAT'&:P3RCLI •✓U'2 f_✓ rmST.ALLEI2'S:NA.ME&.PHO'NE O, i �. SEPTIC'TANK CAPACITY � +f pa^%+s� /Cr��o t^r�s'e. S✓-/o LEACHING,fAC-It.iTY.(cvgo) 'X L p NO.OF BEDROOMS PER24UT DAT.E: Ut7&1r�L A�ICk ISA1 ,.Separation Distan"lie wecn the, „.. Ma imvin Adjusted G oandwatei Table ic+the Botlem of I,eactrin FacUity Private roarer Supply Well and-Leaching"Factlity(IFam wells-exist on - site or Within 200 feet of.leaching facility) Fcc;t- FdRe of Welland and leaching Facility If'any werlands exist tsrthir, 300'rew of leaching facility) Fcet _ 'Ft;tz.'VIJt-Ir`n.HY :'�"-'�"`.y`,� ...G'.��`'e.'�'�,C''!.�•• v.: C s` : 8 - 3 7.� " f / ' .tea ca t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i Commonwealth'-of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Circle V� Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: WM Check Slope ❑® Surface water 0 Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 144" (>5' below SAS) feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 4-22-2015 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 II c Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... 255 Compass Circle Property Address Donald Prouty Owner Owner's Name information is Hyannis Ma 02601 6-6-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: FEW A. Inspector Information: Complete all fields in this section. ❑® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked 0 C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed R D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached "For 15: Explanation of estimated depth to high groundwater included I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATIONaZ,f_�_ C_®iW�if-1Zr G/pf. SEWAGE# `=ILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Cr,rC, LEACHING FACILITY: (type) CGS GGZ (size),-,"-?X 9 5'—, •Z NO.OF BEDROOMS .3 ' OWNER �/Q��/ ��4!✓ PERMIT DATE: COMPLIANCE DATE: ` Separation Distance Between the: 1� ® �✓/�� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility eet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �J � •��®�� _ 1 J �- I;L 37 A � 6 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 21ppl Lation for Bisposal 6pstem Constructions Permit Application for a Permit to Construct( ) Repair(, Upgrade( ) Abandon( ) ❑Complete System adividual Components Location Address or Lot No.c7 S"�' Co�p�i�'�!' CAX Owner's Name,Address,and Tel.No. Assessor's Map/Parcel :YJo 5'B Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 0,7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(minCC/ggquired) G gpd Design flow provided gpd Plan Date 7 —� Number of sheets ' Revision Date Title Size of Septic Tank� �-///'� �p Type of S.A.S. C '� C� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board H lth. Signed Date Application Approved by Date V . _ Application Disapproved by Date for the following reasons Permit No. Date Issued / .7 a No. d/. Fee ;j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS .4 application for MisposaY 6pstem Construction permit Application for a Permit to Construct( ) Repair(LY Upgrade(•,) Abandon( ) ❑Complete System �dividual Components Location Address or Lot No. �{XP Gl� Owner's Name,Address,and Tel.No. o�S``.J°i �QiJ10" Assessor's Map/Parcel 9 Xy - OVa2 4 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. J^!1'� �`'� Type of Building: Dwelling No.of Bedrooms " Lot Size sq.ft. Garbage Grinder( ) w. Other Type of Building ��`� ,+� No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1. Design Flow(min.required) 3 Q gpd Design flow provided gpd Plan Date 7 —� Number bf sheets 100, Revision Date Title .0 1 Size of Septic Tank o. W"f�;�/'°� Type of S.A.S. Ca'' d-74 'J- 4` Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board HeaIth. Signed _ Date Application Approved by O 21 Date �f-- �- vi , Application Disapproved by Date for the following reasons Permit No. - C Date Issued TH L COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by �/,OW at+ 21 CG' /�/�•f`f' C/� Jyy has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..2d f) 'O 9�f dated Installer X-11 ooy 2940;r4e y� Designer . +✓/,� 6,/'OJ'� -'� #bedrooms 3 Approved design flaw j9 gpd The issuance of t is permit shall not be construed as a guarantee that the system will7fhnction as designed. Date z I ? Inspector V a 1y Jr No. ) 4 ( y`- n 1QQ Fee /ad THE COMMONWEALTH OF MASSACHUSETTS _ - PUBLIC HEALTH DIVISION-BARNSTABLE;MASSACHUSETTS MIsposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at �✓�lii/�9l/`T -�� /�' /7��, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must(be completed within three years of the date of this permit. 1 Date Approved by �v \..:1 Town of Barnstable 1HE r Regulatory Services NAP C� Richard V. Scali, Interim Director k BARNSTABLE, 9�A MASS, �0$ Public Health Division lE039. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 g�' Installer &Designer Certification Form q Date: �� ®�"! Sewage Permit# ,` �� Assessor's MaP\Parcel Designer: Installer: -__J UL( Uel Address: �i�o"yL ^�i Address: 4'+A� On � was issued a permit to install a (date) (installer) -. septic system atl%? based on a design drawn by (address) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or §Aq5tic tank. Strip out (if equired) was inspected and the soils were found satisfactory. g 0 k L4 TT� _) I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ' 1nce with the terms of the IAA approval letters (if applicable) OF4,f,;,s y4J /oz DAVID B. (Installers Signature) j ti1ASON r+1 rJo,106 v; CIS e inn i� ture (Affix Desi a& p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable Barnstable .� Regulatory Services Department KAM 1 i � ' Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0321 4/01/2015 Sandra B. Radzik % Donald R. Prouty 40 Acre Hill Road Barnstable, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located 255 Compass Circle, Hyannis,MA was last inspected on 2/_19/2015, by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The leach pit had stain lines at and above inlet invert. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\255 Compass Cir Hy Apr 2015.doc ! t i. 'jF ® Application Center xi Application Center Parcel Detail 0 x - s - ' a issgl2l�ri�a��et,,ip da to/Parr eINJI aspx ID 947 A s htt --www,town,barn...;; pp � p �Application Center ��Suggested Sites Imported From IE IE Parcel Lookup F1 New Tab � ;� Bing ideo;S Incredible Tin... Ifir t �. own E j�rt9titgaTAtii�� F' / .. ;a " od1 w. 77 fa ` •—Parcel Info., — Parcel ID 310-429 Developer Lot LOT 43A Location 266 COMPASS CIRCLE I Pri Frontage 136 Sec Road J Sec Frontage Village HYANNIS Fire District HYANNIS Town sewer exists at this address No Road Index 03400 Asbuilt Septic Scan: Interactive Map . Owner lnfd 44, owner RADZIK,SANDRA B Owner%PROUTY,DONALD R Streett 40 ACRE HILL ROAD Street2 city BARNSTABLE state MA Zip 02630 Country Acres 0.24 u use Single Fam MDL-01 Zoning RB Nghbd 0104 Topography Level Road Paved a utilities Public Water,Gas,Septic Location Coiistruction.lnfo ! Year 1979 ( Roof C;ahlalHin Ext Wnnd ShinnlP ' Computer name : HEALTH899JF User name :.flvnni Ooeratinq System : Windows NT (5.1) 1 I '� r Commonwealth of Massachusetts / W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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. A. General Information 1. Inspector: I I l Shawn Mcelroy Name.of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 2-1.9-15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board Of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under. the same or different conditions of use. �J ~ t5ins 3/13 Title 5 Offi I I ction Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Cir 'M Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 31'0 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 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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 Backupof sewage into facility or, stem com onent due to overloaded or 9 Y Y P ® ❑ 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form t; o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) f Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ M 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 Inspecbon Form:Subsurface Sewage Disposal System•Page 5 of 17 , Commonwealth of Massachusetts w Title 5 Official Inspection Forme - - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 255 Compass Cir 7M Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? .E ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts m F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 .page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 2-2015 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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: Owner--pumped 12-2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: I ® 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 t Commonwealth of Massachusetts _ f Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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: 1980's Were sewage odors detected when arriving at the site? ❑ Yes [ No Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. n Septic Tank(locate on site plan): Depth below grade: 6"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 gal 611 Sludge depth: t5ins•3/13. a# , 1. Title 5 Official Inspection Fprm:Subsurface Sewage Disposal System•Page 9 of 17 41j Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Compass Cir 'M Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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 26" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-3113 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 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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 N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit had stain lines at and above inlet invert. 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•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 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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.): r I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts F Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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 i rr q r y r f r � y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1'5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.� 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water r ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 16' 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: USGS and town maps show groundwater at greater than 16'. 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 m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 255 Compass Cir Property Address Sandra Radzik Owner Owner's Name information is required for every Hyannis MA 02601 2-19-15 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•?113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �3 _ CIt„3�3s' Town of Barnstable P# lq� ce anJ ' Department of Regulatory Services Public Health Division Date N g 2-0 i o5' M-491 ed3g6 �� 200 Main Street,Hyannis MA 02601 X . rEb AAEd� b� Date Scheduled_ �-� Time Fee Pd.- 1 Uby r:. Soil Suitability Assessment for ,sewage_ isposal Performed By: /_,nQ M°/�"^ Witnessed By: D(��'y LOCATION& GENERAL INFORMATION Location Address 5`' Owner's Name y Address J�41W,67- 71 3/� T �� p Assessor's Map/Parcel: � Engineer's Name NEW CONSTRUCTION REPAIR Telephone# 3�7 Land Use Slopes(96) Surface Stones Distances from: Open Water Body ft Possible Wet Area tt Drinking Water Well ft Drainage Way ft Property Line ft Other It SIMTCII:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I V Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ Weeping from Pit Face Estimated Seasonal High Groundwater DETE RMINATION FOR SEASONAL HIGH WATER TABLE Method Used: _ Depth Observed standing in obs.hole: In, Depth to Soil mottles: _In. a Depth to weeping from side of obs.hole: In, Groundwater AdJustment f[. Index Well# Reading Date: Index Well level Adj,factor 4 AtQ.Groundwater Level a PERCOLATION TEST Observation E Hole# Time at 4" Depth of Perc Time at 6" Start Pre-soak Time @ Time(V-6") End Pre-soak / Rate Min./Inch Site Suitability Assessment: Site Passe Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OESERVATION HOLE LOG Dole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. omiMency.%Gravel) A Pi / L 6 C.vyto DEEP OBSERVATION BOLE LOG -Hole# Depth from Soil Horizon. Soil Texture Soil Color Soil . Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o sisten % ra .DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture '5oil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistcncv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No '_/Yes Within 500 year boundary No es Within 100 year flood boundary No— Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us In terial exist in all areas observed throughout the area proposed for the.soil absorption system. If not,what is the depth of naturally occurring per ious material? Certification I certify that on �9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CUR 15.017. Signatur Date f� Q:WEPTICNPERCPORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: (;�) .Jc hr014 6 0/ Owner's Name: Z. �i q Owner's Address: oLSSCo,-7 rc /e sZ.. 3� Date of Inspection: //. ,0o O Name of Inspector• lease print) G7r� �0Ise Company Name: && i — G / Mailing Address: P0 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes J , CD Conditionally Passes c� Y Needs Further Evaluation b the Local Approving An Y PP g ��tY .� Fails Inspector's Signature: 2!) Date: � a The system inspector shall sub it a co of this inspection report to the Approving Authority Boar of Health`or Y P PY P P PP g tY DEP)within 30 days of completing this inspection.If the system is a shared system or has a design fl w of 10560" M gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional ffice of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and a approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: d-1—rU coGv! ti S< 6 r C 010 Owner. Fra Date of Inspecti /i o Or Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A�ZI sses: e 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. S tem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titlas G Tncnontinn 17 rm 411 VIAAA 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a�,j ((0 o tisl rC Owner: Date of Inspee ion: C. Further Evaluation is Required by the Board of Health: A/ 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 15303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titlo Q incnortinn Rnrm Aii;/Innn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: SS t,on 4jf Ct Owner: Date of Inspection: 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 legged SAS or cesspool _✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or pesspool _ -/ quid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped . %y portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ �1ny portion of a cesspool or privy is within a Zone 1 of a public well. �y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria n are triggered.A copy of the analysis must be attached to this form.] �N (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to detern ine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes I 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. T41. i inonortinn rnr 4/1 ciinnn 4 ` Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: L-)\Jrs Ov`l Owner: Fr'o, 04- O�6 oy Date of Inspect' n: / 30 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o /L Pumping information was provided by the owner,occupant,or Board of Health ere 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 P ' ection? � Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior ected for te con of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge anpd depth ofscum ditton `�— Was the facility owner(and occupants if different from owner)provided with information ' maintenance of subsurface sewage disposal systems? on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 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(3)(b)] TitlA C Tncnorfinn Fnrm rii annnn 5 " I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ASS Ca V-I 4ss C fc le 001�co/ Owner: Fly Date of Inspec n: // 30 0 O CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 30 ( DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Ah Number of current residents: / 1Ae""n,� Does residence have a garbage grinder(yes or no): / ` Is laundry on a separate sewage system(yes or no):�[if yes separate inspection required] 77w Laundry system inspected(yes or no):ZOO, Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: tj//c✓T COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFO TION Pumping Records y Source of information: Was system pumped as part of the inspection(yes or no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE SYSTEM — eptic 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if kno );nnd source of* tion: Were sewage odors detected when arriving at the site(yes or no):/ v Tals+ S Tncnor.tinn Fnrm A/Tcnnnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L,--SS 0✓''l R,Sf ]- �Gv1F1/ . 4- OoZCO� Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron a4 P C_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:— (— locate on site plan) Depth below grade: Material of construction:_t/concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 01 2 Scum thickness: I—eSf / 'i <i Distance from top of scum to top of outlet tee or baffle: �/ Distance from bottom of scum to bottoms o outlet tee or baffle: How were dimensions determined: /�0 clefs/ree Comments(on pumping recommendations,inlet and outl a or baffle condition,structural integrity,liquid levels as re ted to outlet invert,evidence of leakage, tc)- 404L r7ee J,J 00 cja av� .Le a LT GREASE TRAPj�locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tit1. 17^rm 411 ci1nnn 7 • Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C>?-S O it,js 61v G '� poL6 O/ Owner: 1011— Date of Inspection: / 3 0 0 TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:/- (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:/V (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41A G inenartinn Fnrm r,n ci,)nnn 8 r ✓ Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c;q, J9 CD✓,1 4!::�t,,- Owner: r p Date of Inspecti / 3o pr SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typelel/ aching 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 ondi 'on of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. : 0 O CESSPOOLS:/—f/(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Title i fncnartinn Rnrm ail cnnnn 9 " Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ASS ( O o ass Owner: T--ra, Date of Inspecti : SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. C �GtG4, 4 .f� a � S�Nte ��- - i7 ' Title G Inenurtinn Rnrm 4r1 ;Ilnnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ['[' SYSTEM INFORMATION(continued) Property Address: �`-'-� �a cm tiSs ('I,- Owner: lam, Date of Inspect on: 0 SITE EXAM Slope Surface water (� �, 0 Check cellar l Shallow wells 110 a(� Estimated depth to ground water a feet CO f+m O- Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: qbeefued site(abutting property/observation hole widjn 150 feet of SAS) Checked with local Board of Health-explain: P Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must des c 'be h w you established a high ground water el vation e D G� OG✓ ��o„ele O.4- ��.t IOC�.TvON f S o21 ' /1 OvE wd r a ry•I g et o/` Ih V &17 Titla C T—n—inn Fnr /./1 G/7AAA 11 N& THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I�IAe'.)....................OF... ..&� q 4-1&........................................... Appratiatt for Msposal Works Tottstrudioupermu. Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: -Lai, ti ddras Lot NO. It Own ._... .......... . ........ ................................... ............... ......................................................... m Installer Type of Building Ad&en Dwelling—No. of Bedrooms..........L.............................Expansion Attic Size Lot....104-A0.......Sq. feet Garbage Grinder 04 Other—Type of Building .1244c.A........ No. of persons........(.................. Showers 6e Cafeteria Other fixtures WW Design Flow.......5-L.........................._.gallons per person per day. Total daily flow.................-Y-2-A..............gallons. Septic Tank—Liquid capacity.komp-gallons Length.......q!.....Width..f.............Diameter................Depth-............... Disposal Trench—No......... .. Width....................Total Length............_......Total leaching area..*A-*7-----sq.ft. Seepage Pit No..................... Diameter.................... Depth below inlet..............:.... Total leaching area...............sq.ft. z Other Distribution box ( ) Dosing tank ( Percolation Test Results Performed by r.aL-746d,-1................... Dat .4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water... Test Pit No. 2................minutes per inch Depth of Test Pit..............._.. Depth to ground water......................._ 04 0 Description of Son.....4jQ.*-:*x0..2'eA' .............. ........... . ........................................................................................................................................................... .......... ..................................... ....................... .. ......................................................... ......*........ ..........*'***"*...........................*..........*-----—-------—----- Nature of Repairs or Alterations-�—Answer when applicable..................................Agreement ............................................................ ..............*.........*...*....*.................................................................................................... The undersigned agrees to install the aforedescribed Individual,Sewage,Disposal System in_accordance with'..-:-. the provisions of TITLE 5 of the State Sanitary Code—The undersi.gned further agrees not to place th7 system in operation until a Certificate of Compliance has been y isst b,Led th b rd of hail . . ..... ..................... Z1 Application Approved By ,e"ie4e*7------------------------ Application Disapproved for the folImping reasons:..:. ................ .......................................................... ................................................................... ............................................................................................ Date Permit No.._.......__... Issued THE C9MMONWEAL>FH OF MASSACHUSETTS BOARD ,iOF HEAUTW OF............ . .. ... ........................................... (Irrfiff4ft of Tomplianu. THIS IS T construct or Repaired 0 �TIF , T. ��Jhe Individual Sewage Disposal Sy-tA� led by... . ......... V ....... ........... —-------- e has been installed in accordan?ewith the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works st ..w ruction Permit ...# 16091 ............ dated... at THE ISSUANCE OF THIS CPRTIFICATE SHALL NOT BE CONST, UED AS A OUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..:........._............................................—------ Inspector......__...................................... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . 7 .. .... ..................... /6:4-11)....................OF......0:,�. ............... 14.0............ ........ Fzz... arm AiPosal Work Ttradion Firutit P Wion is hereg�'granted.. . ........"t-nf.................................................................................... to Constitict�(.,/) or gepair �1 d iv i d, at No...A-L:L` al.,L Sewage Disposal System Str e et ....................... as shown on the application for Disposal Works Construction Pe gwq No. -O- al ad..... .......... Board of Health •............ DATE... ................................. FORM 1255' H00138 4 WARREN, INC.. PUBLISHERS '1 r i,Y�d►f}' �.�,i,�,i �i f i� f.!{~'v f.t�,t,�,��' �r.•+* fFa�t r'i+�Y `:l�i►�'�1 :�.+ ��"iM'""t� ?�� "t � Y �.* t .'M; `�`�..' .� !@'ry • .e`M �,� A ,e i � ,i by p., 71 �.'� .�,;,p1. r .F ' y tt }qd' S y»',I,�` t. ,r�.•• •� � 1 k !?} gri•`!4 -r �4'' I.;r,y�dy ,.r ",�"'.'"` tt, ti :4 2; c '{ �-r 7l t ��t r T 6 tam 4.1 • .0 b d L• y�. `:f k. KI sw F awe$ � ,•t _ .�< r: - Kart t,:` }`�� ' r.. � s, �a N.•.a r ' .. �,*' • s rc �" ,, , rx (/��] .. \..fir r �/.�) �' .•4J *' f .Y. t r y Y c A• T{ r 4 or i'4.9i?\. � �•_k'Kd �'t�� . .l i.7f t Ly"�y n,,t q y'� +� _ }4t t t ,�� •: �•��{.,/ •; ��',,y�f r�.- yy ! .1 �� a �L; > ;; �-•, a'i' isfil� pp��u ti a.• �i� ,yK. s r i 4 ♦:12 + +, ` ., a..�' 't1 y43. . Y 7i'� ,P�4�. t uy �• �* ..:t 93- �S .._ a � -JlS♦• "yy�'L � #'!�r>~ b '�^ 4 S r�• Y .. f r, r`i , $ - �-1�raj`. 4 � �f•�,•��,+"�� ' � � :*'. 'y'r, �y „'�` "fit Q A M s s 3•. t I� to rr h.." SA• 1 .s j � 9 .^/ I Id 41 r ♦ ♦ L :z t Ste, 't�". ..�: . -�^^�--ems►.p' O 4` +tom•t 46 4 ' 4 a rta� R• .y v • ,,t. ,,,. . . .. >r ,: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 1 PART A CERTIFICATION Property Address: 255 COMPASS CIRCLE HYANNIS LOA L-2,� Name of Owner JOE MOLCAN VEO � Address of Owner: 198 HANSEN RD.NORWICH CONN. S EP 2 Date of Inspection: 9/14/99 � OF �999 !N Name of I am a DEP approved roved sease 'Ystem inspector Ppursuant to Section 15.340 of Title 5(310 CMR 15.000) LlppEpL'�E ♦ g. Company Name: n/a A Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.,The system: X Passes The Inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs FurthJElu n By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:9/16199 The System Inspector shalit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. 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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING THE SEPTIC TANK NOW AND THEN EVERY TWO YEARS. I revised 9/2/98 Page 1 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9L14199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 44, revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page g 3 of 11 >! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nla. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. . X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)j X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 P '� Page 5 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14199 RESIDENTIAL: FLOW CONDITIONS Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 220 Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): NQ Last date of occupancy: n& COMMERCIAL/INDUSTRIA Type of establishment: nla Design flow: nta gpd(Based on 15.203) Basis of design now: n(a Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): XQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: Wa OTHER: (Describe) nta Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection:(yes or no):NQ If yes,volume pumped W& gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nta APPROXIMATE AGE of all components,date installed(if known)and source of information: 1979 Sewage odors detected when arriving at the site:(yes or no) N_Q revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 256 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 14_ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: K Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ Wa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: 3E 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: 1C How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE TRU TURA Y SOUND RECOMMEND PUMPING Y TEM KNOW AND THEN MAINTAIND EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction concrete metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa ` Distance from top of scum to top of outlet tee or baffle:_nLa Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wa F revised 9/2/98 A' Page 7 of 11 "I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 256 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wit Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nla Dimensions: Wa Capacity: nta gallons Design flow: nfa gallons/day Alarm present: MO Alarm level: n/a Alarm in working order:Yes—No—: NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wit DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) I]La PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): MO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wit revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON OCTAGON PIT leaching chambers,number: 1]La leaching galleries,number: _uLa leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: nLa Alternative system: nLa Name of Technology: 1]La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND F NTIONIN PROPERLY-THE PIT HAS NOT HAD MORE THAN 2 OF WATER IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)D& Comments: (note condition of soil,signs of hydraulic failure,level,of ponding,condition of vegetation,etc.) nLa PRIVY: (locate on site plan) Materials of construction:nLa Dimensions:nta Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa F revised 9/2/98 r Page f 11 a ego SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 266 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a C c 0 sg LO AA II AR �� 6c �c 3y revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 255 COMPASS CIRCLE HYANNIS Owner: JOE MOLCAN Date of Inspection:9/14/99 NRCS Report name: nta Soil Type: nta Typical depth to groundwater: nta USGS Date website visited: n/a Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: - Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USES MAPS AND CHARTS-12+FEET revised 9/2/98 t Page 11 of 11 I -�G �� . � �� '�> r-0 �� 9/ � I z, , , TOWT�Cif $ TST E fLOCKIION � 5 •... A"S�Sa4)Tt'S N1.91'8i L0 O i VILLAe6"e 4 K .a ` i1�15T L.Edt'.S i+tA�1tI�I3c 2' I61,11 No. ..: L Cl CE S�,p rutiagi c,t�uare; cstv�teil Sloe Feel Mxi�numl�sl)ustccl Geauc�cSw�tt�e 1'� leta tlaG�attom ai X�;achta i lcility Pity ae;�'J tur u131ily ..NO Midtown n�?aduty .W any�rf,19s cxtsi a :vvlehia'2tlQ feetle�u� dahtus fariiity) cl .crfi V�ltVanr�s �3ec6unt, aclity.GY�any N��taaci5 ease : ,e; v131�ua IQ{1 f�et q&leact�n�fard>xry) :� j c;GJ✓i :/" d~ur4 hod by �J � �� , � � n W � � � `�C � �a � rn� a �. o _^ � \J v � U a r .,� 'J TOWN-OF BARNSTABLE 'LOCATION � °��f��SS C rc SEWAG # VILLAGE ASSESSOR'S MAP LOT �2� L•Z Im ",kNSTALLER'S NAME 8c ONE NO. .� ySEPTIC TANK CAPACITY (� l®oo c'LEACHING FACILITY: (type) 11"(� (size) "NO. OF BEDROOMS -BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -� o ' r CPO 7qR" rl+ L"OCATIO SEWAGE PERMIT 0. - VI-LLAGE l V ,Z42zs I)NSTA LLER'S NAME & ADD SS ` X BUILDER OR O NER DA T Ef. ;PERMIT ISSUED DATE C 0 M P L I A N C E ISSUED�� l.- l \/V No....................... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ... ........................................... ........ ... Apofiration for Bhipoiial Wlarks To n g tru rti on Vamit. Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: -Ift................... .................................... .......... pp Acati Address r Lot No ..... ------------------------------------------- .........&------ Lot -------------------------------------------------- Owner Address .................................................... .............../............................................................................. Installer Address Type of Building Size Lot.....tP411 ta........Sq. feet U Dwelling—No. of Bedrooms..........(c:..............................Expansion Attic Garbage Grinder '_l 04 Other—Type of Building ........ No. of persons........(.................. Showers Cafeteria Otherfixtures ----------------------------------------------......................................... ............................................................. Design Flow........5-5.............................gallons per person per day. Total daily flow................. ..............gallons. 04 Septic Tank—Liquid capacity./Ai?agallons Length------q....... Width-_-F............ Diameter................ Depth.............._. Disposal Trench—No..................... Width.................... Total Length.._..............._. Total leaching area_!1:-4..7......sq. f t. Seepage Pit No--------------------- Diameter.............__..._. Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) C Percolation.Test Results Performed by....�elw.,j.... ..................... Date.....-_�-j 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.__.._.............._... .............................................................................................................................................................. 0 Description of Soil..... ..... . -le................................................................................ W - ..... U ............................................................;.................................... ......................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable.---------------------------------- ............................................................ ...................................................................................................................................................................1.................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITLE 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Wbeen iss 'd by the board of I:ea been iss let . Ined.... .. . .... ....... ............................ ............. .. ........ to Application Approved By__....... .... ............................. .. .. ....... . at Application Disapproved for the following reasons--------------------- 1 .................................................................................... .........................................................................................................I.............................. ................................................................ Date PermitNo......................................................... Issued_... .......................... ..... ............ Date �1 NO........... .:................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH Appliration for Dispotiai Works Tnnstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual .Sewage Disposal System at: • Locatio -+Address C �yqr Lot No. ? a=`-•--.LIP....... ...................•---.........---.............. ........�:=p---=...:......-:�::•G�ttl C'./.................................................. r Ownl'r Address . �,� =....._...�_.... .........------................. .........._..__. Installer Address Type of Building Size Lot.....kr:.{S()__......Sq. feet Dwelling—No. of Bedrooms..........L..............................Expansion Attic ( ) Garbage Grinder ( ) aa, Other—Type of Building ../ _:_ A-,c..._..... No. of persons.........(_•................ Showers Cafeteria ( ) aI IOther fixtures .........-••--••-•-•--•-------------------------------.. WDesign'Flow...........-`..............................gallons per person per day. Total daily flow.................. `_?..............gallons. W _Septic Tank—Liquid capacity.n:n? gallons Length......q...... Width... :.......... Diameter................ Depth................ x Disposal Trench—No..................... Width....................... Total Length.................... Total leaching area...`t_ ..1......sq. ft. Seepage Pit No,_.-.--•............. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by..... ..................... Date........ .......... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._ fX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x -•----•----•........................................•--- ---.........---------.....--•-•--•------•-•--•-----------•...---•-•••...-----•-•----•-•--•---•--... O Description of SoiL.... ........ s_'l�...?_:�:�.__.... %r ------ ------•-•--............................................................. V ........................••-•------•-----•-..........._.._.........................._------•-----.../----------•-•••••••••---•--------------••-•----------•-•••-••------•----------------•--•--__---- W �..� U Nature of Repairs or Alterations—Answer when applicable . ................................................_..........__.. Agreement: The undersigned agrees to install"the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiT . r 5 of the,°State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Cd"'mpliance has been issu•d by the,board�ealt�/�grned......... ' f ,� Date Application Approved By ......... _ 4 / Date Application Disapproved for the following reasons:.....................;..._..- ---•--•-----------•--•...••--•--•-----------•••.._......•..................••- ---------------------•-------_......................_...-----...-----...•-••-••-------...........•-------...-•--•----•..__...-••-----•••----....._..-••-•--._.__._........---•---•--------------•••_......................... Data PermitNo.................................................. ---. Issued........................................................ Date ,." THE COMMONWEALTH OF MASSACHUSETTS BOARD IOF HEALTH ...................QF..:. �<s!.� ............................................ . �rdififatr of Tontlrgianrr THIS IS T�OPTIF)', Th�''t•'the Individual Sewage Disposal System constructed'( ' ) or Repaired ( ) ,.lr j Installer,' at........................................ �` l! ------ •---•-------------- ------ has been installed in accordance with the provisions of T/ � 5 of The State Sanitary Code as described in the application for Disposal ��Vorks"Con _*Construction Permit No._. ___. .__ ________________ dated.. THE ISSUANCE OF THIS CtRTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. s' DATE................................................................................ Inspector.. '- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?� I OF......6 �2...` ,!.. No.._.. ....- .. FEE................ .•-•- �,.,,isposd nrkp- �an #�i uan an it Permission is hereby granted...t fir. ''��a....�:.1....................................................................................... to Construct, q)qor Repair (^� ) at�i' ndivi al Sewage Disposal System at No... �_�._ .f.!._._� 7 r .. £ Street =' as shown on the application for Disposal Works Construction Per No._._ ..�-.-____, ated.....�_�?._:�_ ' Board of Health DATE--- ,l fr .. FORM 1255' HOBBS & WARREN, INC., PUBLISHERS , , r x , m XIIV43N GtA0¢11 42kj - rllvCSN afrAve sIrAve t 0 vErt IrA N K 4✓ERL /�'iT s ��x,o �'� ` .r- # �N• s.160 Oo,rdvKO. f � s", �`" �� "�1vR►.�,/►"i'a✓a¢p�+✓dy�Jli�ESr+F`�l7/ � r UweL.t,.i/V G \jo 4 i CA-Ld-A tz F-L, "__.__ �` 1 A t Vie- y D !ST �`-�'4 ALB✓ �t�n ,1 1 t�� IQf. /NFk7 GEri v ,OAC , 6 ?� , / A G4u 4Nslt7 S`T'4N� d ew i Se Level, ` ., AND S7A8 ` W 1,>_,e S t Gib' CAI r'dr PI �; z 4yC.,�`f a y.P• Gel�+ �4•� (J/Q� - ��^ �' _- T^ - ,� :: . � N L 4r,44*/A/ ,,;Per! �vll1,E� © L j I.J T '�> - 1~D N I<N Ic Y' �hJ�Y t, .,. ` `41 +... . Act_!_'a. ; 5 t x ,' _ 3 7 y PP F 2 k- K P.Y -N_ L as t 4 Oi r�r��'�: - li►j Tee- . 4r;A P Cr S U i w 1 tir w # i » bX 1 r & 7 C 1:,Lki;,1't'l� r� r' i ©P�3.� 'C.� 1�O 'FA U L U 14-AY r A K U �� i 1 F /\��" -� ,/ /� �,�� a1� G.�IN6 "" n �«� �, ,G€,�►c'- ,e,Urf� � � /�n! 3..t •J�-i �►�-E-1 .,�_ F��►�.�: r c,.� t�R�"�"' •_ - -� - of , r n. C ASSESSORS MAP : ---- ------— ---- ---- _ - - T E.S T HOLE LOGS t-� ✓ PARCEL: # q �- - y29-----__.._. _---- - - _-_---- ----- + 1) The installation shall cornt�ly with Title V a>>J Town ofh(�3oard of FLOOD ZONE: SOIL EVALUATOR: I I lealth Regulations. pc)? 4 .__ -_ ___-.__ _ __.._.__.__._ WITNESS : (Z- 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: a��. DATE: k components prior to installation and settingbase elevations. �. PERCOLATION RATE- -,,—,'-G Z. 1 � P `-�,�I / �,�� "�^_�.7�-�1.. _.. .__. _ _ _—.�� _� � 3) . All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per Foot. The first r��^-� 1 �, �I-�y.�y � '� two feet out of the d-box to the leaching shall be level. TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. Lro `O ►Ac �� 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over II10 septic components. Z v7) The property is bounded by property corners and property lines. �� 1 � 10 LIo ;✓ 8) The property owner shall review design considerations to approve of total LOCATION MAP 3� _ �Z . design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall d � 1 be removed along with contaminated soil and replaced with clean sand per Title V specs. 10)System components to be 10 feet from water line. Sewer !fines crossing the water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the ---- � owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. BEDROOMS ATl 0 GAL/DAY/BEDROOM GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer dines exiting the dwelling"rior to the installation. I 14 '1 his plan is representative only that a system can fit on a property meeting SEPTIC TANK ) P P Y Y P P Y g — — -' Title V requirements. 1 (d GAL/DAY x 2 DAYS GA _ 1p USE [ GALLON SEPT I C TANK CE�C *k- ' ` 0 Ii�BsORP ION—SYSTEf tJ .0 OF , "SIDE AREA: 2X IZ.��j�j -1- D► 1 I ,�� v aAvt� �2 �(1 BOTTOM AREA: p 1 = ZZj7?j MASON f ' No 1066 0 �y �J tStE N' , T I =C SYSTEM SECTION 0S Hid Aid, jo —DoGAL �, J-n SEPTIC T NK l�Z�C✓� t j ter,Z_ SITE AND SEWAGE PLAN LOCAT I ON : 65" P R E PARED F O R : P I 4� /qm M 1 tr 1 0 SCALE: W DAV I D B . MASON RS DATE: 0 Z DBC ENVIRONMENTAL DESIGNS a z EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833- 2177 W Z l 1