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Home My WebLink About0375 COMPASS CIRCLE - Health 375 Compass Circle Hyannis F/R A = 310 447 i TOW gOPSARNSTABLE LOCATION SEWAGE #OY-A g VILLAGE g*,*A- ASSESSOR'S MApP &/SLOT 2/�'� PT INS,TALLER'S NAME&PHONE NO. P49�®�� `7�0 Z 3®o SEPTIC TANK CAPACITY t4*100 LEACHING FACILITY:r(type) iDD 6AC t,,.e,U> (size) /�•2' NO. OF BEDROOMS BUILDER OR OWNER 5 PERMITDATE: COMPLIANCE DATE: Separation Distance<Betw.ten the: ;:��: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 �'�A,`� 1��W V C��,�O �' � .,, N, .. r� 2r�a3 Y® ' No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for ;Dtgoal *p!tem Construction 3permit Application for a Permit to Construct( . )Repair(grade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. ^ Owner's Name,Address and Tel.No. Assessor's Map/Parcel �� yy 3� C� ?/ elrc�e Installer's Name,Address,and Tel.No. ! Designer's Name,Address and Tel.No. D,,,, vvep g no7 e,_11 Type of Building: Dwelling No.of Bedrooms of Size sq.ft. Garbage Grinder( ) Other Type of Building 6 VAA o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 Q .7 V gallons. Plan Date ' `4 - U'_� Number of sheets Revision Date Title Size of Septic Tank (Jd Type of S.A.S. @G 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 Certifi- cate of Compliance has been issu this Bo e Signed ` l Date 3 Application Approved by Date 2 2-y 3 Application Disapproved for the following reasons Permit No. -2-UO 3- f5 Date Issued 3 4`4; # f A 3 Gr LJ No:> Z0 l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V t u r Yes PUBLIC HEALTH DIVISION -TOWWOF BARNSTABLE, MASSACHUSETTS K 2ppricattonJor 33igoal *p!tem Congtruction Vermit Application for a Permit to Construct( . )Repair( V'Upgrade( )Abandon( ) El Complete System 0 Individual Components Location Address or Lot No. 3� Owner's Name,Address and Tel.No.C«�l-e L �.� Assessor's Map/Parcel � ,,�� CG /�f}'—�C/✓C'/� . lv j yN Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. )_�-,((/v`Po /�n P f3 P ��ex �d a Va tic s� ti. Type of Building:. Dwelling No.of Bedrooms �ot Size sq.ft. Garbage Grinder( ) Other Type of Building .`,kUn�P cc,�., �o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date ti - 0, Number of sheets ( Revision Date Title Size of Septic Tank )60 Type of S.A.S. .� v 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 g �' ,� g P Y in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued-by th ss Bo r otl1e-aa1th. Signed f �r Date U 3 Application Approved by Dater IV Application Disapproved for the following reasons, f Permit No. Z 00 3-. ``(Os t Date Issued X-2 2 1.16 3 ------------.------ ———a-- -------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( A Upgraded( ) Abandoned( )by C VC A4 u(A -t-7 0-J at 0!;S c C LP has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZW 3- 'rOSdated ?2 Installer 7 mac- ,,� i �►� ,,, � �_ Designer 0A The issuance of this permit shall not be construed as a guarantee that the syste I t tf as7 sig Date_, - ZZ-03 Inspector No. 2003 Feer- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoot *p$tem Construction Vermtt Permission is hereby granted to Construct( )Repair( L1 Upgrade( )Abandon( ) System located at 2 q S Cuv'WO( sS r iil L C L and as described in the above Application for Disposal System Construction Permit.The applicant recognizes 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. Date: �- 2 Z -U 3 Approved by `� TOWN OF BARNSTABLE LOCATION SEWAGE #0�`�og VILLAGE EtAN>irh ASSESSOR'S MAP & LOT-3��" � INSTALLER'S NAME&PHONE NO. P"710 `7 z - f3g9o, SEPTIC TANK CAPACITY l®�� j LEACHING FACILITY:r(type) gDD ��C.� k1le U2 (size) �f A' NO. OF BEDROOMS J BUILDER OR OWNER Le -1,s PERMIT DATE: COMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Tablet 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 i >r I i �3 ® COMMONWEALTH OF MASSACHUSETTS u EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION P0RECEIVIC. 2 Z003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP Property Address:_�i7C' � PARCEL . LOT Owner's Name: ns Owner's Address: Name of Inspector: (please print- Company Name: o wwn Septic Inspections Mailing Address: R0 Ekx 145 Telephone Number: A 02632 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 maintenancq of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: P`Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails inspector's 6tgnature: - ^(.�� — ,vary: i r r c✓ The system inspector shall submit a copy of this.inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments y3 rev 'V N w 13 -a 2- *""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. � r ' Title S 1ncnPrtinn Fnrm I; /1000 _ -_.►_ Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J Owner's Name: �e wt S Lt N da Owner's Address:. Date of Inspection: [- 1 0-3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: I have not found any information which indicates that any of the failure criteria descnbed in 310 CUR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. onditionally Passes: one or more syste mponents as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon co letion of the replacement or repair,as approved by the Board of Health,will pass. answer yes,no or not determined(Y, )in the following statements.If"not determined"please explain. The septic tank is metal and over 20 ears old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or tration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a Table. ND explain: Observation of sewage backup or break out or high static w level in the distribution box due to broken or Obstructed pipe(s)or due to a broken,settled or uneven distribution box. in will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced I 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: '%,Z Owner's Name: N Owner's Address: . mate or inspection: C. r e lnation is Required by the Board of Health: Conditions exist require further evaluation by the and of Health in order to determine if the system is failing to protect public h safety or the environmen 1. System will pass unless Board eal etermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a In which will protect public health,safety and the environment: _ Cesspool or privy is wi 0 feet of a s ce water _ Cesspool or privy is 50 feet of a horde vegetated wetland or a salt marsh 2. t%yo 1 fail unless a Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that or-o-fftU the nahlic health_sofeN P"d P�rn"—PW%#- _ the system has a septic tank and soil absorptio stem(SAS) the SAS is within 100 feet of a surface water supply or tributary to a surface water sup — The system has a septic tank and SAS and the is a Zone 1 of a public water supply. _ The system has a septic tank and SA d the SAS is within 0 feet of a private water supply well. The system has a septic SAS and the SAS is less than 10 t but 50 feet or more from a private water supply well**. od used to determine distance **This system pas the well water analysis,performed at a DEP certified labor ,for coliform bacteria and vol a organic compounds indicates that the well is fee from pollution fro t facility and the Pre sen ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided no other failure criteria are triggered.A copy of the analysis must be attached to this form �. •.�rnrec:y l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) rrup�rty AplYre88: �' �• � Owner's Name: Owner's Address: _Lrus 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 _t/lackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -,,'Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓Liquid depth in cesspool is less than 6"below invert or available volume is less than%Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed oipe(s).Number .>.. ion_...,r.....rof... !�Any port 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. _V 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. _t— ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] too (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. F. If.asp Cacfomc? 1;o nt�reeB ered a large system the system must serve a facility with esign flow of 10,000 gpd to 15,000 gpd. You must indicate eith "or"no"to each of the following: (The following criteria apply a systems in addition to the eria above) yes no the system is within 400 feet of a surfa g water supply — the system is within 200 feet of a td to a drinking water supply — — the system is located m a m en sensitive area(Interim We Protection Area—IWPA)or a mapped Zone II of a public water poly well If you have answered"yes" any question in Section E the system is considered a si cant threat,or answered "yes"in Section D abov a large system has failed.The owner or operator of any large m considered a significant threat un r Section E or failed under Section D shall upgrade the system in accordance with 310 CMR Page 5 of I 1 ..- -- --- -'--- _-"" .- •"^-•+ o.-:.. r'vao v i Al lJl V 1 Al'�At7►iJ�7L`i'fi71VYL'j\Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: cs � N\ Owner: Lk e Date of Inspection: 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 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? t� 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? a� Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? ✓Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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)J Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner's Name: c LO Owner's Address: Date of Inspection: I FLOW('o"rrrnwe Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CM 15.203(for example: 110 gpd x#of bedrooms):Number of current residents: _ Does residence have a garbage grinder(yes or no):bm Is dry on a separate sewage system(yes or no):A.V Cif yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no):Water meter readings,if ava�apip ble(last 2 years usage(gpd)):. Sump pump(yes or no):1 Last date of occupancy: �r,�,+ OMMERCIAL/INDUSTRIAL: TYPt-Qkestablishment: Desitm flo sed on 310 CMR 15.203): Basis of design ts/persons/sgft Grease trap present(yes Industrial waste holdin es or no):re (y _ water m dings,if available: d9te of occupancy/use: THER(describe): Pumping GENERAL INFORMATION P g Records Source of information: Was system,pumped as part of the inspection(yes or no): Pj If yes,volume pumped:`dons--How was quantity pumped determined? Reason for pumping: TYPE YSL-19TEM ePtic tank,distribution box,soil absorption system —Single cesspool `Overflow cesspool Pri 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) _ --emu--•----- ._ ".,vpy vi we iujzr approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(ves or no): Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Owner's Name: ,...� — Owner's Address: Date of Inspection:_ j - I -(yam BU ING SEWER(locate on site plan) Depth below Materials of construction:_ t iron _ 0 PVC_other(explain): Distance from private water su suction line: Comments(on conditi ants,venting, ce of leakage,etc.): SFPTir TANK! (In—vto n�• Depth below grade:�� Material of construction: l�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: -j( (( �' , G 1 Sludge depth: C7 tl Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:-0 _____ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leak iiiiipe,etc.): 646- �-.� n.v.nAn•1 GRE TRAP:_(locate on site plan) Depth below gr 1 Material of construction. concrete metal_fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outl e: Distance from bottom of scum to bo of outlet affle: Date of last pumping. Comments(on pumping endations,inlet and outlet tee or a condition,structural integrity,liquid levels as related to outlet inve vidence of leakage,etc.): Page 8 of 11 I%1%VTd"V A T ••••.._ �o vx.a✓a v+a�►i'rJL �`7►�3A71JIII1:Y►71Y.Y�1'1 Y iJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C f Owner's Name: Owner's Address: Date of Inspection: 1 1 —d TI or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: --con ^_ metal` fibesgl ss_polyethylene other(explain): Capacity: aaLo Design Flow: ons/day Alarm present(yes or no): Alarm level: m working order(yes or no): Date of last p e 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):_ c"rt c9 t CGtfCVC�J� CHAMBER (locate on site plan) rumpb m woncmg orrdee Alarms in w er(yes or no . Co (note condition of pump chamber,con s and appurtenances,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .1�-_ , oil- a Owner's Name: Owner's Address: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_pocate on site plan,excavation not required) If SAS not located explain why: Type leOhing pits,number: —I eaching chambers,number:_2_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): . S A S NP�� C OOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and co Depth—top of liquid to inlet' Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwa inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: n site plan) Materials of construction: Dimensions: L Comments(note condition of soil,si of hydraulic failure, Lf ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Owner's Name:_ (.p 1.1,E ct Owner's Address: Date of Inspection: 1 1- 1 " 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. a Ak - �7 2-" 9,3 N3 - Tf ALA 2 i3 � - lg i3-3- 1 `t Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C avaIMwr Property Address: ;�'7 57 CcXna%S C Iftt Owner's Name:__ Owner's Address: Date of Inspection: fy'3 SITE EXAM Slope% S tb P kNc, \N 404 k Surface water% kXXJV Check cellar: Shallow wells N G N Estimated depth to ground water ja±feet 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: v v0,,w a11C.k4VU,,U11E", 11V1G W1,11",1JV IV,"Vl Ot1.11 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: N--o we Aer C�Ncov� rc�l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P RECEIVED, JUL 2 9 I'll TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 375 Compass Circle FAILED INSPECTION Hyannis, MA 02601 Owner's Name: Linda Lewis Owner's Address: Date of Inspection: July 16, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 310 Mailing Address: P.O. Box 49 Parcel: 447 Osterville, MA 02655-0049 Lot: 34 Telephone Number: (508) 862-9400 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 Conditionally Passes Ne s Further Evaluation by the Local Approving Authority ✓ Faj s Inspector's Signature: Date: July 20, 2003 The system inspector shall subm t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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 I ' Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 Inspection Summary: Check A,B,C,D or E/.ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,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: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 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 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: I, 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface 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 11 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. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components, excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum.? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable . Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd 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 INFORMATION Pumping Records Source of information: Pumped in Oct. 02-per owner Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: Qallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approx. 1979 Were sewage odors detected when arriving at the site(yes or no): No 6 J Page 7 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 1" Distance from top of sum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick 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 liquid level was above"theoutlet tee, backing up from the leach pit. GREASE TRAP: None (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.): 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: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 TIGHT or HOLDING TANK: None (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.): The D-box was under a very large tree and not accessible. Liquid was backing up from the leach pit. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 . SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits, number: I - 6'x 6'- 1000Qa1. 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.): The liquid was above the inlet pipe and up to the cover. The leach pit was in failure. The bottom to grade was 8. The cover was 2'below grade. CESSPOOLS: None (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: None (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.): 9 y Page 10 of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 Map: 310 Parcel: 447 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 34 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. a a 10 Page 11 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 375 Compass Circle Hyannis, MA Owner: Linda Lewis Date of Inspection: July 16, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and failed of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. ll YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to.operate.) Business Certificates are available at the Town Clerk's Office, I"FL., 367 Main Street, Hyannis,MA 02601 (Town Hall) II : DATE: -6-o 1 Fill in please: APPLICANT'S YOUR NAME: _421s � Zg ��5 BUSINESS YOUR HOME ADDRESS:3'lS f! �S_S . TELEPHONE # Ho e Home Telephone hone Number a8- `l Do Z p S � 6 9 NAME 0=NEW8USINES$ " . ' TYPE OF BUSINESS. P IS THIS.A HOME CCUPiATIQN? :;:YES _NQ Have you been,given,approval from the building.Aivision? -YES O _ ADDRESS OF BUSINESS 7 E� 'MAP/PARCEL:NtJMQER When starting a new business.there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St,-!-_(corner of Yarmouth Rd.&Main Street to make sure have you y v the a ppropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COIVIM R'S OFFICE This individual,has i forrwed ny it requirements th 'attain to this type of business. MUST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS. FAILURE TO Auth riteMatur " * —A - COMPLY MAY RESULT IN FINES. COMMENTS i 2. BOARD OF HEALTH This individual has been ' f rmed of the permit req ' ents t attain to this type of business. MUST COWLY WITH ALL orized Signature**. HAZARDOUS MATERIALS REGULATIONS COMMENTS: . CONSUME AFFAIRS LICENSING AU ORI R A TH This individual ha n infor of the li 'in®rQ"c}�(rcments that pertain to this type of business. z Authorized Signature** 1��C._. COMMENTS: Hazardous Materials Inventory Sheet Checklist -_,Vim fjate hysical Street Address-Check database to ensure it exists orking Phone Number Actual Amounts-(ie.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) Storage Information-location of storage,how long is storage for? ]4ehic"e'Washing/Rinsing? ne,note that. osal Information-where and who?If none,note that. icant Signature-understand what is listed and noted nttial-any questions,know who to ask -provide a vehicle washing policy and expWin it-note that it was given Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures thev are doiri . Notes need to be left to explain what you discussed with them. -� Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 11-le Ina ' C0�icLeIcA� BUSINESS LOCATION: 315 is C-IieZo "A_ INVENTORY MAILING ADDRESS: Ir TOTAL AMOUNT- TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: Cllene� e0 -�.e� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids —' (dry cleaners) .4>0 .440,f_ _ Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSI SS YOU WISH TO OPEN A BUSINESS? I For Your Information: Business certificates (cost$40.00 for q years). A business certificate ONLY REGISTERS YOUR NAME in town (wh ch you must do by M.G.L.. -it does not give you permission to operate. YGu must first: Obtain the necessary signatures on this form at. 2�00 ,Main .., Hyannis. Take [het completed form to the Town Clerk's, Office, 1 st. Fl., 367 Main St., Hyannis, ,1/iA 02601 (.Town Hall) and get the Business Cc i-0 ic'ate that is required by law. DATE:C - 5 Fill in please: APPLICANT'S YOUR NAME/S: GUD BUSINESS YOUR HOME ADDRESS:_; ` >~<' .„/ 5S i'i2 � /,¢�:p.7 ivt�r TELEPHONE # Home Telephone Number NAME OF CORPORATION: - --mai-irlyi, z <e NAME OF NEW BUSINESS TYPE OF BUSINESS ed)-1' 7 C1ZX;�-.. IS THIS A HOME OCCUPATION? ES NO. nn ADDRESS OF BUSINESS a - t MAP/PARCEL NUMBER ��1/ (Assessing) f When starting a new business there are several things you'must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST OG TO ROO Main St - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual.has be in he permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business.. Authorized Signature** COMMENTS: ,.f ii TOWN OF BARNSTABL.E Date: to/ ZS/ TOXIC AND HAZARDOUS MATERIALS ON-SITE I NAME OF BUSINESS: ." 4nae ' BUSINESS LOCATION: ®- ��it � S �� - INVENTORY MAILING ADDRESS: C, c �ucrc ,�Y� , �} TOTAL AMOUNT: TELEPHONE NUMBER: —C-6 Z 6d�l CONTACT PERSON: ,SX'0 $*,C EMERGENCY CONTACT TELEPHONE NUMBER: °'off- �l /D��Zf� MSDS ON SITE? TYPE OF BUSINESS: flay G� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with"poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS App;1cas Si n lure Staff's Initials BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop 1 Date of Inspec} ,y Map �D arcel `J Owner It . PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. --'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 COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. ,/THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. i ,;--"ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. i !i THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED j FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. I-- THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. i THE FACILITYOWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL / No of Bedrooms Q Ir No of Current Residents Garbage Grinder i c's Laundry Connected to System Seasonal Use i NON RESIDENTIAL: i Calculated flow WATER METER READINGS,IF AVAILABLE: I i GALLONS Pumping Records and Source of Information: �, SYSTEM PUMPED AS PART OF INSPECTION? I�YES, OLUME PUMPED GALS Reason for Pumping: TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes, attach previous inspection records, if any) Other(explain) ;Azpprximate age of fall components. Date installed,if known. Source of information. Yr7e SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: �, Dimensions: Material of construction: oncrete Metal FRP j� Otherrl Sludge Depth 19 . Distance from top 3of fudge to bottom of outlet tee or baffle O Scum Thickness 011 Distance from Top Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle 0 Comments: �// SA,dq e a DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER:, —Pumps in working order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE:. — D O n el'), Comments: 9v1�� h PL CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SXSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' DEPTH TO GROUNDWATER: 6 DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y-yes N-no ND-not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? / Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? /►Z Within 50 feet of a private water supply well? I Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools &privies only, not the SAS)? 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 compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY ASSESSORS MAP : U TEST HOLE LOGS NOTES: PARCEL : �y i 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH t 2% FLOOD ZONE: 00 j 1Z SOIL EVALUATOR : i�EXI(:% (�.�, � AN 995BOARD OF HEALTH REGULATIONS. TOWN OF �k WITNESS : ) REFERENCE: C'Ns"M DATE: 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RAT : L 7 AA SEWER SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO 3 CLA�5 2 `j6IL. LT 2. = O ?To' !^ v INSTALLATION. 0 TH- I E[, I�_gp TH-2 + 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION j ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE S DETERMINATION. �v Flu, '� �7 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS SPECIFIED OTHERWISE) C1)1 UM A LOCATION MAP � 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A SA J�D GARBAGE DISPOSAL. 7/ ( 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) z� �/ MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. -7)��Yj UAA� Iiiii��(,q PT 3c= Pvmta(FP, 'r"s-OP), 14) 6 -1t� ._ _a_ io�..F � _.uF._Poo_ rt SEPTIC' SYSTEM DESIGN --- 4.__......:.-.__�_... 9,�9,�� _ N ,, J/o• -_19G�_ 1N71<.:tero�e.. PUVMr3�Nfit 70 � 7EN !.c , __ _ r /iv7a S/ .� .... .__.._. �.. ......__. ._._. . Nl Z 9 FLOW ESTIMATE c-Xtsnn/ aUR-I+ P r PE, (f'COAI tT Ml) 9C RF- I sr \ 3 Il. K/s77nr �c,rt_. ,.�v , _lr,>"�, /1� �z BEDROOMS AT l�C� GAL/DAY/BEDROOM - 3.30 GAL/DAY 9 \ Mtn SEPTIC TANK 33Q GAL/DAY x 2 DAYS GAL USE / ' GALLON SEPT i C TANK—�X/ST1^/� - RM'C�i�c w/ /SC��S'�`>° L-- �p lF FA-4,610 D44144 oft) ok SHED ' SOIL A830 SPT I ON SYSTEM uNn ,sr�ED ,4-I 64 c� wrf �s �� rUl�' 1 � ?S 17 S I Dr' AREA: �ZS Z t3 Z K 0, 7 � l/Z. S/8` _ \ BOTTOM ARE Z5"k /i x O. �y �' ► '�-� (ivom SEPT I C SYSTEM SECTION o ( c � o 7?-5M = 7-OF 5c, . o r �XlS`nN4 3 f32 ssII v"- ... _� . __ E� ��.° t 7. o �' Cove ..— _...x.�_.....-....,�...�. �_ s off _ O a E trK/ !a� et,, Iy.So L 3 16.33 - -- Q s R /� /3 D-BOX �E I� c" _ 7-0 000 GAL AA-ka L� T.� 7,1 �? 8,.&o /r✓'tG ,+z. /3. SOU SEPTIC TANK ,� / L �0&X- _ Loo.&a3 N/y o8 /L ( 'IrXIS77N/� {� eveln emu` EX?s77A �/ W'494eo 25" L X f 3' tA) -�- �H OF Afq SITE AND SEWAGE PLAN E FATION . 375 EOMl-f a Cleeit e C EY R flYit/N/,S 1� o. 1140 PREPARED FOR : 6EIkli S4NITAR�� ' �'03 01 Ix ,' DARREN M. MEYER, R.S. SCALE :0. 43 VINE STREET iz DATE l�LA, aF L� rJrJ, yAN4UgVy DURY, MA oz z ��V�- A. (1/� 1Zl fivJ ��s 22 t��`a DATE HEALTH AGENT (781) 85-0293 -