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Home My WebLink About0028 CROCKER DRIVE UNIT BLDG 6 UNIT A - Health 28 CROCKER DRIVE Hyannis ,A, = 3 06 — 030 — 00_ (4 units) i No. 1 L/ J O (0 Fee d" I Entered in computer: THE COMMONWEALTH OF MASSACH�SETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Disposal 6pBtrm (Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(w ❑Complete System ❑Individual Components Location Address or Lot No. �� ( Owner's Name,Address,and Tel.No. 1MON(QvE C—�LtYCe4V Assessor's Map/Parcel Q 3 ® -0 (3 3r53 HYA k)(S p 6QT Installer's Name,Address,and Tel.No. 5 p%—q 77_ 77 Designer's Name,Address,and Tel.No. 401P6cvt0E 8wmj¢.P41ce 1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 of Health. (� Signed ` Date Lr C7 "1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 1 Date Issued l �:T No. CJ `�� f /. �';� ; Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(ppYicatiou for_Misposal 6psteit Construction Permit E Application for a Permit to Construct( ) V Repair( ) Upgrade( ) Abandon()� ❑Complete System ❑Individual Components Location Address or Lot No. a g CQ�7G ��0.0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel t/ ��r�v� `� v4wsitS koiLzr Installer's Name,Address,and to.�Npo.�5 0ye_4 77—1? 77 Designer's Name,Address,and Tel.No. ery °`. e-AP 5T Type of Building: .Dwelling. No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 'J i Nature of Repairs or Alterations(Answer when applicable) 'Date-last'inspected: n Agreement: f.. w The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in . 1 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 of Health. »L Signed Date 10 " 71 // t Application Approved by Date Q tD Application Disapproved by Date for the following reasons Permit No. 3) Date Issued 14 ------------------------------------------------- ----------- ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS -- BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X)by (--J at 12 ",peVW has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit NoR.1,LJ 39kdated /d/ Installer 6= Designer #bedrooms ! Approved desMi n flow ' The issuance of this pe it hall 6t be construed as a guarantee that the systemnictions designDate Inspector / _ 11 V -------------------------'------------------------------------------------------------------------- No. � �•-� ^ ,�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at � ( Q 1� �c 1,t✓ '6� 1 i I, 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. " 1 Provided:Construction mus �be co ple a within three years of the date of this ermit. - Date n (c��l Approved b i I a � No. � Vv . ': in� Fee THE COMMONWEALTH OF MASSA HUSE Sr��U Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplitatlon for -isposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A) ❑Complete System ❑Individual Components Location Address or Lot No. a$ C e0C=i4E jZ b3Z A:t P, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 30� d ®E PU eUic (`to(cto4 t4VAux/4,5 NISI Installer's Name,Address,and Tel.No. 50 Q—q Z 7-g%-1-7 Designer's Name,Address,and Tel.No. (3406WI®& C-Pn pvu ses c.c.s t414 153 c t� T— P Type of Building: Dwelling No.of Bedrooms /V e ' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures orA Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7f j?,4�1 00M tk/�5/rI XJ6 St;]�TtC_ !i�_Y57GLA 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 of Health. Signed Date Application,Approved by Date Application Disapproved by Date for the following reasons Permit No. O Date Issued it— f --------------------------------------------------------------------------------------------- ----------------------------------------- 10 No. Fee � :`�, r ice!�F.��i I V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLICjHEALTH DIVISION.-TOWN OF BARNSTABLE, MASSACHUSETTS Applitation for Misposal 6pstem Construttion 3permit Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components Location Address or Lot No. $ C(ZpVcAEV_ 1)7L J:t ;k Owner's Name,Address,and Tel.No. 141 WIJ5 1-6,V#4Ett kE1t,5TL-A'D Assessor's'Map/Parcel 30G O3Q dpG PO eUX Vcto4 (-/YAUXAS MA Installer's,Name,Address,and Tel.No. 50 g"q 7-7-'8$-1'7 Designer's Name Address,and Tel.No. �S r- S Pam— N/� Type of Buila mg: . Dwelling No.of Bedrooms /V Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) - gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) - ��-Daly �/Srr�� S�TrG. SYSTc7v1 Date last inspected: Agreement:The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been.issued by this Board of Health. �. Signed Date 0 Application Approved by , Date Application Disapproved by Date for the followingreasons Permit No. 0 �" — "" 4 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifitat>e of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned o()by dA 9 C--w(b r_ ELjZgW!_Zt (4L,, at a;$ C(Ly GUI P Q lUr#,j jy&)0j 5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. %dated �� ! �Z -f q Installer )f 16Ef 1. C_ Designer / #bedrooms Approved design flow /`� gpd The issuance of this permit shall not be co stre as a arantee that the systemtill tionasdesigned. f Date / Inspector h' - - --------------------- ------------------- `-------------------------------- � ----------------------------)--- No. o !r L f L 4-3 Fee 95. "V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at A9 CQ�GLrc(Z, ladtly� #a I��A1ty� and as described in the above Application fon,Disposal System Construction Permit. The applicant recognized his/her duty to comply with t. �r Title 5 and the following local provisions or;special conditions. Provided:Construction must be completed within three years of the date of this permit j ( ( -- - Ic-� ,k Date � Approved by ' VI _ u _ I^( No. / �� k Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9ppfitation for Misposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components Location Address or Lot No. b�P_ #3 Owner's Name,Address,and Tel.No. W1t��C. �Ia-4TDc�lc>e!(C.(� Assessor's Map/Parcel 3® a 6 0 FQ 4,egY 5r m8bp IMt4 Installer's Name,Address,and Tel.No. 7� —q17-g{'l-7 Designer's Name,Address,and Tel.No. TcPS�s l4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 of Health. Si d Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. —3 Date Issued �i' N Fee j THE COMMONWEALTH OF MASSACHUSETTS Etitered i.computer: Yes PUBLIC HEALTH DIVISION -TOWN"OF BARNSTABLE, MASSACHUSETTS 01pplitation for ;Disposal *Pstem Construction Permit Applic,ation fora Permit to Construct Repair Upgrade Abandon(X 0 Complete System El individual Components Location Address or Lot No. ag a Q-OcKe-e-bz, 3 r Owner's Name,Address,and Tel.No. MtcvAr=c- i4PAT-0CJ,4WjL(., Assessor's Map/Parcel 3oj7 1z)3ojo6 r> A > In Fort"T 5r MaDy(ET-1) M Installer's Name,Address,and Tel.No. 50§-q7 7-F�9'17 Designer's Name,Address,and Tel.No. expat'j(piz GPT ev-palses L.,.,C, 153 60W44tQWJ4<., z5r- X*+Qk9&%E WIA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( Cafeteria( Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank s Type of S.A.S. "`Description of Soil Nature of Repairs or Alterations(Answer when applicable) 46&40#j 6X(SZ(&,& 7Y6VT1C S: 1VS1?DXA 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 of Health. Sig ed�� Date Application Approved by Date Application Disapproved by Date for the following reasons 10 1 Permit No. J5 i 3 Date Issued ------------------- --------------- ------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded Abandoned(X)by COWeW(W QL,(Z, at CAO"G-7- D R. 0 Y 4-1J)U 3 has been constructed in acc�Lrdance with the provisions of Title.5 and the for Disposal System Construction Permit N,�;P)C4 73 '9")dated hq, I Installer (!WGIOIVI!e� �OJAS�A(965 4f-C, _ Designer A #bedrooms I Approved dosign flow /Y gpd 7P,/Or/� The issuance of this permit shall no c st as,adarantee that the system i 1 C ak des Date Inspector V - ------------------------- ---------- -------------------------------- No.�& )L-� — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction Permit Permission is hereby granted to Construct Repair Upgrade Abandon(X) System located at 22 c&ockjae, 7v-iu4g Hy4x) 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 b -om le e�,Aithin three years of the date of this p.rmit. Date Approved by S � �� -13 �--U No. V�� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposal �6pstrm ConstrUttiori permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components Location Address or Lot No. A 2 Gino c,iGtEq (7� Ny Owner's Name,Address,and Tel.No. W t c, 7 --", Rooms Assessor's Map/Parcel 3 o Q Q 00 �, l 3 3 G d x S-T v o S o N M A Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Ce4i06-te_>ibG ?W&-S c,cr_ �1,4 GOcu CI sfltt� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A(3Ao Da 0 E,?US—( (Q Gr- S EPTIC YV,STE)IL-1 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 of Health. Si ed Date Application Approved by Date �d Application Disapproved by Date for the following reasons Permit No. -Ziff Date Issued No. / Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ye ftplitation for MispoBal 6pstetn Construction Permit Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components Location Address or Lot No. AiR C2o c.KEP. DP- HN Owner's Name,Address,and Tel.No. C#4) wt-�� Roo?> Assessor's Map/Parcel 3 o(p O 3 D QO C ` l 3 3 Cox 5-r t-v o s o Q M A Installer's Name,Address,and Tel.No. 5o g_Ltll-&S 079 Designer's Name,Address,and Tel.No. I 3 Goruace2c�!(�sT /ltA�S,�� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building. No.of Persons Showers( ) Cafeteria( ) / Other Fixtures § Design Flow(min.required) gpd Design flow provided r' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .46,4L)j)c)rJ 6�(JST(K)Gr- SEPTIC, S'V,STE I Date last inspected: j Agreement• i 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 o Compliance has been issued by this Board of Health. + _ Si" ed Date 6 Application Approved by Date � Application Disapproved by Date for the following reasons Permit No. Date Issued -------------=-------------------------------------------"--------------------- ----------- -- -------------------------------- TH - j E COMMONWEALTH OF MASSACHUSETTS , C BARNSTABLE,MASSACHUSETTS Certificate of Compliance THISS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned(X)by CAP0vrt,-je E 41Ser at )L2 GR-O C.K69- DkJ)C c YAUXJ/5 %s been constructed in accordance J j with the provisions of Title 5 and the for Disposal System Construction Permit /y dated Installer Installer C4pE7-01 DE 0-� Designer &i 1A #bedrooms Approved design flow gp The issuance of this permit shall n t c ns as guarantee that the system ill fun dfes'gn ed. - Date Inspector ---------- ------------------- ------------------------------------------ ----------- -----v------------------------- ------ No.. " -l Fee D-5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *ps.tem Construction j3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(A) System located at oZ 2 CA QGr_e T)ki v C N V A•N O(S 4) I 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 cpmplete wi.7n three years of the date of this rmit. Date V/, Approved by �v No. / " Fee co Is THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftPliLatton for Vsposal 6pstrm coneit Talon Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon A ❑Complete System ❑Individual Components Location Address.or Lot No. Owner's Name,Address,and Tel.No. Hy. W1 t.F&6D l-fe)o'D Assessor's Map/Parcel 133 Go1c Si' HLA)SOA) A Installer's Name,Address,and Tel.No. 5 h"0 Z-RR-77 Designer's Name,Address,and Tel.No. eA d tDJ 1 A6: e.,j I eee#-A s ES c.X-c— 5 N 1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title - Size of Septic Tank Type of S.A.S. Description of Soil l Nature of Repairs or Alterations(Answer when applicable) &i f .'a'lz L 5L/S'72341 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 oard of Healt Si ned Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / Date Issued V No. x/~ �- J Fee CO- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for misposar 6pstrut Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(tk ❑Complete System ❑Individual Components Location Address or Lot No. ft AS (=P cxX P_-M Owner's Name,Address,and Tel.No. Hy Witc.FAeD HOCZ Assessor'sMap/Parcel 306 030 0013, :45) 133 COY- 5-r Hu-1>5001OLfA In taller's Name,Address,and Tel.No. rj '9-4'17-'RZ-7'7 Designer's Name,Address,and Tel.No. Ao*Ev11)E 4e�eQ�LtsC� wc. NIA S cfxcc�cc�ct�-�. sr H.c�st1A� ''Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 th' and of He Si ed Date Application Approved by Date Application Disapproved by Date r for the following reasons r Permit No. Date Issued b - -------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS `\' c BARNSTABLE,MASSACHUSETTS 1" 1 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned k)by C�n��l�� p�l(�� at Q!9 G/.2 cpe- DP, H Y*JYJ � as ben conk cted in accordance - 3 iy t o�l b l with the provisions of Title 5 and the for Disposal System Construction Permit N �ated Installer LLC--Designer A #bedrooms Approved design flow _ gpd o The issuance of this permit hal not bp yons-tr0d as a guarantee that the system will fucion aglde�,Iigned.> - !.01 Date Inspector ff ,# t> a !-'z L/ 1 d!. - ---------------------------------=- - ---------------------------------------------------- ( - --------Fee------- No. ( � �'" l — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposar *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at a8 CRoC1C.cg- Nuuiz t4 yA&W( S Q$ 1 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 /m lete i i ee years of the date of this ermtt. ? Date ��/ //�� Approved by SEN'DER-,COMPLETE.THIS SECTION COMPLETE THIS SECTION ON DELIVERY M ■ Complete items 1,2,and 3.Also complete A. Signature I item 4 if Restricted Delivery is desired. ❑Agent I ■ Print your name and address on the reverse XIC4: Addressee so that we can return the card to you. B. Received by Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, I or on the front if space permits. YA Is delivery address different from item 17 ❑Yes 1. Article Addressed to: 02 0 f YES,enter delivery address below: ❑No � MONIQUE'A'GALIPEA , TR U�-R H r� GALIPEAEAL EST TE TRUS , D I PO BOX 553 I, . HYANNIS PORT, MA 026 Ceruffgd Mall ❑Vpress Mai ` [�Yfi�F,�eglstered etum Re el r Merc n e I`-- ; ❑�1n� red Mail ❑C.O.D. & 4? stricted Delivery?(Extra Fee) ❑Yes 2. Article Number F i 7012 1010 00q'0 2'848 21,03 II (Transfer from service labeq PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 : I UNITED STATES POSTAL SERVICE First-Class Mail i - Postage&Fees Paid USPS Permit No.G-10 I I • Sender: Please print your name, address, and ZIP+4 in this box • I I Sewer Connect Public Health Division � s a Town of Barnstable I 200 Main Street Hyannis,MA 02601 ' I � I i 1III�li'llli,�,lirllil' l'IIIII„„iIIII'UI'11111IIII'IIt1I"'1tI m o o OFFICIAL I co Postage $ rU Certified Fee 0� C3 V S Postma C3 Return Receipt Fee Here C3 (Endorsement Required O � Restricted Delivery Fee C', O (Endorsement Required) C� O Total Postage&Fees s ti Sent To MONIQUE A GALIPEA r a GALIPEAU REAL ESTATE TRU o -eer o,P§& PO BOX 553 i °r" HYANNIS PORT, MA 02647 Certified Mail Provides: " o A mailing receipt io A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years { Important Reminders: e Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. e Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. }— n For an additional Jee,4 delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" n If a postmark on the Certified Mail receipt is desired,'please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ..... .. ... ....._ IMF, Town of Barnstable Barnstable Regulatory Services Department 1 f snxrrsr�et,e, � ' b �,m __ _ . _ . _-_ _ -._ Public-Health Division m 200 Main Street, Hyannis MA 02601 20 7 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0103 March 28, 2013 MONIQUE A GALIPEAU, TR GALIPEAU REAL ESTATE TRUST PO BOX 553 IMPORTANT NOTICE HYANNIS PORT,MA 02647 Map & Parcel: 306- 030 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 28 Crocker Drive, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF HE BOARD OF HEALTH homas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA1LING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc k Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a rig nder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties-that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstab]e.ma.us/cdbQ (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PubI1cWorksTech/se.weri.nstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc SENDER: COMPLETE • • . DELIVER ■ Complete items 1,2,and 3.Also complete A. Signatur item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X H, ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, gar on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No HEATHER KEIRSTEAD I P O BOX 1904 HYANNIS, MA 02601 3. Se ice Type I j Pertified Mail C3 press M ❑Registered WAeturn R pt for Merchan e ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) 2. Article Number 7012 1010 0000 2848 0097 I (transfer from service labeq I PS Form 3811,February 2004 Domestic Return Receipt, 102895-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 I � Senders- Please print your name, address, and ZIP+4 in this box • I II I Sewer Connect i Public Health Division I w,U Town of Barnstable I 200 Main Street M Hyannis, MA 02601 M • - __j 1a��1"lil��'1��!l11111111airafi�.�lrfil�ijiiill'l'1��'fl�:l�l�t�# U.S. Postal Sery e�TM � CERTIFIED MAILTM FiECEiPT, (Domestic Mdn,OMy;No Insurance Coverage Provfded),s, 't � For elive information;vi§it our website at www:us s.com r � 11. � �ry ■ Pl' _. - ♦ J I -I ♦ 1 .1 P�Form 3800,August 2006f See Reverse for,lnstruc ions`': Certified Mail Provides:- o A mailing receipt c A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years t Important Reminders: a Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested":To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. o For an additional fee delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Deiivery° o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Barnstable r Town of Barnstable .�. Regulatory Services Department AMMMIU j BAMSfABM I , NAM �0 _ Public Health Division_. 200 Main Street, Hyannis MA 02601 7 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0097 March 28, 2013 HEATHER KEIRSTEAD P O BOX 1904 IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 306- 030'DOE The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 28 Crocker Drive,Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF T E BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA1LING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through y9ur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.nia.us/cdbg (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PublicWoi-ksTech/sewerinstallei-s. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER conneeftLetters Stewart Creek Sewer COnnects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete . Sign ure item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse 0 Addressee so that we can return the card to you. eceived by(Printed Name) C. Datelof D liv?ery ■ Attach this card to the back of the mailpiece, L�G or on the front if space permits.. D. Is delivery address different from item 1? WY es 1. Article Addressed to: If YES,enter delivery address below: I WILFRED & ELENA HOOD=' 0- 133 GOXST HUDS'.ON MA 01749 3. Se-ri��e Type Otertified Mail P, press Mail Q 61J ❑Registered I FRetum R �forMerc D dise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) - ❑Yes II 2. Article Number 7 012 1010 0000 2848 0080 I (Transfer from service labeo PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS ` Permit No.G-10 I � • Sender: Please print your name, address, and ZIP+4 in this box ' I I Sewer Connect Public Health Division I Oa Town of Barnstable 200 Main Street Hyannis,MA 02601 ` I I I IId11'1l:1l.11111111111'iltlill1111111i'11illi'fiilil��:�le�1a1� I e. ca .. o '. OFFICIAL ' coPostage $ \� nj Certified Fee Postmark O Return Receipt Fe c Here C3 (Endorsement Required) O Restricted Delivery Fee O (Endorsement Required) a O Total Postage&Feesti(r�" r s WILFRED & ELENA HOOD a a 133 COX ST2�z HUDSON, MA 01749 Certified Mail Provides: p A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mails. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery'. a If a postmark on the-Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 f - r Town of Barnstable Barn tME T ti Regulatory Services Department M�MnlCeC j sa�tvszaei.�, Noss' g, I - ,,- -.-.-- .,Public..Health_Division. _----------------_- -- -_.- m_ . 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0080 March 28, 2013 WILFRED &ELENA HOOD 133 COX ST IMPORTANT NOTICE HUDSON, MA 01749 Map & Parcel: 306- 030,oDI5 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 28 Crocker Drive, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page., PER ORDER OF T BOARD OF HEALTH omas A. McKean, R.S., C.H. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connectEetters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc (F►.1 Y E P Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through y�gur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdbg (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PublicWorksTech/sewerinstalIers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connectTetters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM . PART A CERTIFICATION Property Address: 28 Crocker Drive #4 � _Hyannis Owner's Name: David Wright _ Owner's Address: 1 61 Bay_Lane Date of Inspection. e5 ) Name of Inspector:(please print) i William E. Robinson Sr Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville MA Telephone Number._(� g l 7 7 5-a 7 7 F CERTIFICATION STATEMENT t certify that 1 have personally inspected the sewage disposal system at this address and below is tru that the informal"e,accurate and complete ton reported . p as of 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 Se tion 15340 of Title 5(310 CNIR 15.000). The system: Passes E `� Conditionally Passes Needs Further Evaluation by the Local Approving Authority , q" Fails Inspector's Signature: > g Dstte: The system inspector shall submit a co this inspection of report to the Approving Authority(Board� Health xw- r`r' DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional olice ofthe 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 1 Page 2 of l l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Drive #4 HYanni . Owner: Date of inspections - Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: " I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or to 310 CMR 15.304 exist.Any failure tlure criteria not evaluated are indicated below. Comments: B. System Co ditionally Passes: One or mo system components as described in the"Conditional Pass"section need to be replaced or aired.The s ste re P y upon completion of the replacement or repair,as approved by the Board of Health,will pass.. Answer yes,no or not gtetmincd(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is m 1 and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantia infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with 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 han 20 years old is available. ND explain: Observation of sewage ackup or break out or high static water level in the distribution box due tabroken or obstructed pipes)or due to a b ken,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 pump' g more than 4 times a year due to broken to obst xted pipc(s).The system will pass inspection if(With approval of a Board of Health): b ken pipe(s)are replaced ob is=Qvod ND explain: Page Tor 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Drive #4 Hyannis Owner: David Wriaht Date of Inspection: . gib C. Further Evaluation is Required by the Board of Health: Conditions exi which require further evaluation by the Board of Health in order to determine if the system is failing to protect pu lic health,safety or the environment. 1. System will ass unless Board of Health determines in accordance with 310 CMR 15,303(i)(b)that the system is no functioning in a manner which will protect public health,safety and the environment: _ Cessp of or privy is within 50 feet of a surface water _ Cessp of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Syste will fail unless the Board of Health(and Public Water Supplier;if any)determines that the system is nctioning in a manner that protects the public health,safety and environment: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surf a 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. r " The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frock a pr vate water supply well- Method used to determine distance " his system passes if the well water analysis,performed at a D£P certified laboratory,for coliform ba feria and volatile organic compounds indicates that the well is free from pollution from that facility and th presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other- fa' tire criteria are triggered.A copy of the analysis must be attached to this form. 3. her: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Drive #4 Hyannis Owner: David Wright Date of Inspection: —v . D. System Failure Criteria appy able to all systems: You must indicate').Pes"or"no"t each of the following for all inspections: Yes No Backup of sewage isito facility or system component due to overloaded or clogged SAS or cesspool Discharge or pondiftg of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or Osspoot Static liquid lev I in the distribution box above-outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth y cesspool is less than 6"below invert or available volume is less thin'/:day flow _ Required p ping more than 4 times in the last year NOT due to clogged or obstructed pies of times ed p ( .Number) p p t Any porn of the SAS,cesspool or privy is below high ground water elevation. Any po on of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface Ynifrogen pP1Y• _ pion of a cesspool or.privy is within a Zone 1 of a.public well. nion of a cesspool or privy is within 50 feet of a private_ p water supply well. _ rtion of a cesspool or n pp y p privy is less than 100 feet but greater than 50 feet from a private xatcr well with no acceptable water quality analysis.(This system passes if file well water analysis, med at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds es that the well is free from pollution from that facility a and Y nd tt�e presence of ammonia nitrate nitrogen is equal to or less than 5 p m a triggered.A copy of the analysis must be attached oth this that no other failure criteria t forma (Yesr o)The system fa_ _its.I have determined that one or more o(the' above failure criteria exist as d scribed 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 E. Large S stems: To be consid red a large system the system must serve a facility with a design gpd. flow of 10,000 gpd to I5,000 You must indicate either`y&'or"no"to each of the following: g (The f011owirg criteria apply to large systems in addition to the criteria above) yes no the ystem is within 400 feet Of surface drinking water supply - the ystem.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—I WPA)or a mapped Zo a 11 of a public water supply well If you have swered"yes"to any question in Section E the System is considered a significant threat,or answered . ''ycs"in Se ion D above the large system has Culed.The owner or operaor of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR I5.304.Th system owrer should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 Crocker Drive #4 Hyannis Owner:_David Wright Date of Inspectio41-4 L - c rd Check if the following have been done.You must indicate` es"or"no"as to each of the following: Yes No pumping information was provided by the owner,occupant,or Board of Health v 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? v 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 examin ed?(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 tattle manholes uncovered,opened,and the interior of the tank inspected for the of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum�ition X' Was the facility owner(and occupants if different from owner maintenance of subsurface sewage disposal systems )provided with information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes �rto r/ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria is unacceptable)[310 CMR 15.302 3 is to Part C is at issue approximation of distance ( )ro)1 5 Page 6 of I 1 G OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Crocker Drive #4 Hyannis Owner. David Wright Date of Inspection:V'h -i FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .S DESIGN flow based on 310 CMR 15.203 for example: 1 i 0 d x#of bedr �( p gpd ooms): Number of current residents: its Does residence have a garbage der(yes or no):X10 Is laundry on a separate sewage system(yes or no):k�) [if yes separate inspection required] Laundry YsYstem inspected(Yes or no : Seasonal use:(yes or no):),�g 5 Water meter readings,if available(last 2 years usage(gpd)): C © J." AL eo Sump pump(yes or no):Z,,b a �/ a ,� s Last date of occupancy: COMMERCIALII NDUSTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sani waste discharged to the Title 5 system(yes or no): Water me er readings,if available: Last dat of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: o r4� G f.=,r► - g !;J* Was system pumped as part of the inspection(yes or no): 4 r) If yes,volume pumped:fL_gallons--How was quantity pumped determined? Reason for pumping: TYP 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) lnnovative/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 known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 il'agc 7 of 1 I OFFICIAL INSPECTION 1.0101—NOT I-()It VOLUNTARY ASSLSSAIENZ•S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSIILCTION 1,01ol PART C SYSI'"' 1NFORAIATION(continued) Property Address: 28 Crocker Drive #4 Hyannis Owner. David Wright Date of Inspection: BUILDING 5 1VE11(luca(e on site plan) Dcpdt belt, grade. Dista Materials fconstructior —cast iron _40 1'VC udler(explain): nt torn private%vale(sulgrly well of s CUl uction lint:_ mncnts(on condition of juutls,venting,evidence of leakage,etc.): SEPTIC TANK;Zoocalc on site plan) Depth below grade:- 3 Material of construction: tscvncrete metal fiberglass wl e _utlur(explain) — — —► yUt)lent If tank is metal Iis1`a c certificate) — Is age cunfunted•by a Certificate of Cutttpliar es ar.nu Dimensions: a ) _(attach a copy of . Sludge dcpllr: Distance front top of sludge to t bottom—u(uu�lct ee or baffle: j Sctun thickness: �_ le v Distance front tvp of scum to lull of uutlet tee or bafllc: Distance Gorn bottom of scum to button,of vutlel tee or barlle:4� ' I Iote tare dimensions detcrntincJ: Comments fun pumping(cc onuncndati t�inlc(a td ou Ict tcc or baflle condition, struUwal into rit '---�C— as related to oullet utvcrt,et•iJence ofleakage,etc.); �— �. � )` 6 ),hyoid Ictcls GREASE TRAI';� (locale utt site plant) Depth below gra Material of cons Uiuu:_concrete_tnelal fiberglass—pulycthylerte outer Dimensions: Scull)Iltickrt s:_ Distance fro n lop of s lull of uutlet tcc or bafllc:_ Distance G nt bottom of stunt to boltum of outlet tee or baflle: Uatc of 1 t pumping:_ Count: is(on pumping recontrltendaliuns, inlet and outlet(cc or bafllc cunditiu:t, structural integrity, liquid lcvch as rcla cd to outlet inval,ct•idcncc of icaka fc,cic.). Pacc 8 or I I OFFICIA1, INSPECTION hOltr•I -NOT bolt v o L . . S UN�t'Alt UUSUW ACE'SLIV AGL DISPOSAL SYS71'.NI INSI'I;C'I ION Folz 1N I S PART C S1'STLM INhORAIA'IION(continued) Property Address: 28 Crocker Drive #4 Hyannis Owner: �d jn ri ht Deft of lospcctloo: 4/ $�—G rl TIGHT ar IIOLDING ANK: (tartk must be pumped at time of iuspeclion)(Iucate vn site l,lan) Depth below grade; Material of construe ton:__concrete_metal—fiberglass____ mlyethylene other ex , Dimensions: ( Ilatn): Capacit}•: Design Flow: allvns —gallons/day Aleut presen (yes or no). Alum level: Alanr—i in wvrl in under Date of last )umping; 6 (yes or nu): Cununcnts condition of alarm and flual s%%.itchcs,ctc.): UISTIIIUUTION DOA: t/(if present must be olmicd)(locale on site f►Ian Depth of liquid level above outlet invert: ) Conuncn(s(Wore if box is In•cl and distri Icakage into or out of bux,ctc.): bution to outlets cyval,all)-evidence uf;vlids carr}•over,ally evidence of i'UAtI'CIIAA Cll: ("'Cale on site plan) 1'untps in��•/rking order(yes or to):— Alarms i► "corking order(yes or no):_ Colnm tts(note condition ofpuntp chamber,conditiun of pumps and appurtertan(cs,etc.): Page 9 of 1 I OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Drive #4 HXannis Owner. David Wright Date of inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,ezcavation'not required) If SAS not located explain why: Type �eaching pits,number: r! leaching chambers,numb_er: 3 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.): CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and co figuration: Depth—top of quid to inlet invert: Depth of solid layer: Depth of scu layer: Dimensions cesspool: Materials of onstruction: Indication o 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 lonstruction: Dimension Depth of s lids: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Drive #4 Hyannis Owner:_ David Wright Date of Inspection: 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. 1 A - zp i 10 Pa8g j)- of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- 28 Crocker Drive #4 Hyannis Owner. David Wright Date.of Inspection: `l ?`6 "? SITE EXAM Slope Surface water Check cellar Shallow wells x Estimated depth to ground water 41 feet Please indicate(check)all methods used to determine the high ground water elevation: f 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) ,- ,, l� Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mu escribe how you established the high ground water elevation: s7Sr 11 Certified Mail#7006 0810 0000 3524 9360 �OVVE ro Town of Barnstable Regulatory Services t i ISA.ftNSTAE3LE, ' r$ MASS' g Thomas F. Geiler,Director ib3q. 1� AlfbMA�R Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 10, 2007 Monique Galipeau 34 Crocker Drive Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 1/051 CMR 410.000 STATE SANITARY CODE II — MINIMUM STANDARDS OF ITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 28 Crocker.Drive Hyannis, was inspected on April 4, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.482 —Smoke Detectors. No smoke detector near bedrooms. 105 CMR 410.553 —Installation of Screens. Windows and doors require screens. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by installing smoke detectors within 10 feet of each bedroom and by providing screens for windows and doors. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. QAOrder letters\Housing violations\Rental ordinance\28 Crocker Drive.doc Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and as to speak with the inspector who performed the inspection. PER O TH BOARD OF HEALTH Thomas . McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\28 Crocker Drive.doc THE COMMONWEALTH OF MASSACHUSETTS FORM30 CH&W HOBRS&WARREN BOARD OF H ALTH CITY/TOW liw- o DEPAR� ENT ) .-601 Oy`0 ADDRESS (5o g) 6�&'2-� '�o y q M 3 TELEPHONE Address ' � � Occupant_ Floor Apartment No._—� ___ No.of Occupants_ _ No. of Habitable Rooms 44 No.Sleeping Rooms_ No. dwelling or rooming units_M✓11' No.Stories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: J-x1&0 Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: 40 5 .3 Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation.---- Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1), a,0 o 11Qz- Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: ks, Flues,Vents,Safeties: Kitchen Facilities In Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other:Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." `2V INSPECTOR � TITLE A.M. DATE ® TIME ` y l J� A.M. THE NEXT SCHEDULED REINSPECTION P.M. .r n I 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be.a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. I Nip Page 1 of 1 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® El E3 Zoom oulflUflunflDnIn JPG Map: 306 ,�Ca EP. ©" ❑ Location: m o - Owner: 4 ' Location In t Map &Parce a Location fl Acreage 8 q ' Current Ova ary, Mailing Addi � � �..•� � p�q „„ � _ � .� � Appraised � a D � vs Extra Featur Out Building Land Buildings i IUI a Total.Apprai Extra Featur �e 40, Out Building Land Buildings Total Assess Set Scale 1" = 845 �' � Aenal Photos ?�� Copyright 2005 Town of Barnstable,MA All rights reserved.Send questions or comment! BarnstableMA v0.2.91 [Production] I http://www.town.bamn table.ma.us/arcims/appgeoapp/map.aspx?propertyID=30603000F 4/4/2007 Town of Barnstable Regulatory Services BAMS ASS Thomas F. Geiler,Director MASS 16,19. A�� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 4, 2007 Attn: Hyannis Fire Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector)violation(s): 28 Crocker Drive Apt. #1 Map-Parcel: (306-030-OOF): -No Smoke detector in basement area which is where bedrooms are. Timothy 'Connell-Health Inspecto Q:\Order letters\Housing violations\Rental ordinanceUire Violation,TIRE TEMPLATE.doc COMMONWEALTH OF MASSACHUSETTS 401 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: 28 Crocker Street; Hyannis Owner's Name: Patricia Mu roy Owner's Address: 73 Reflection Drive Date of Inspection: Name of Inspector:(please print) Wi 1 1 jam E_ - Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (S08) .775-9776 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.1 am a DEP approved system inspector pursuant to Sect n 15.340 o[Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: v 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 10000 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 appr6ing authority. Notes and Comments r_; CD i Cn ., "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: 28 Crocker Street # 5&6 Hyannis Owner:_ Patricia Mulroy Date of inspection; Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any-information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM1115:304-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 pipes)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 obstritction 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 nmoved ND explain: l f Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Street # 5&6 Hyannis Owner:-Patricia Mulro Date of Inspection: Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is fai' g 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 ystem 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. S tem will fail unless the Board of Health(and Public Water.Supplier,if any)determines that the . syste 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. s rface 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 front 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 n_o other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: 28 Crocker STreet # 5&6 Hyannis Owner: Patricia Mulro Date of Inspection: -6 D. yysem Failure Criteria applicable to all systems: You ust indicate`des-.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 ies's than'/,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 I00,feet of a surface water supply or tributary to a surface water supply. Any portion of.a cesspool or privy is within a Zone 1 of a.public'well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well: Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and Volattworganic compounds' indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: Large Systems: To a considered a large system the s}'stem.mu'sfserve.a;faci!ity with-a design-now of IO,000 gpd to`I5,000 gpc. Yoi i 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 We Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If yo 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(mmer 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 L Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 Crocker Street # 5&6 Hyannis Owner: Patricia Mulro Date of Inspection: —/Gd'd Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes NY Pumping information was provided by the owner,occupant,or Board of Health i/ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _U 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) l/ ____ 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 baf[l�e 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 ClAR 15.302(3)(b)) 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Crocker Street # 5&6 Hyannis Owner: Patricia Mulro Date orinspection: FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design): �4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 11 of bedrooms): L G Number of current residents: Does residence have a garbage der(yes or no): a Is laundry on a separate sewage system(yes or no): a[if yes separate inspection required] Laundry system inspected(yes or no):dt- o Seasonal use:(yes or no): sv v Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):as e) Last date of occupancy: G L1 COMME CIA ANDUSTRIAL Type of a tablishment: Design w(based on 310 CMR 15.203): gpd Basis o design flow(seats/persons/sgft,etc.): Grease ap present(yes or no): Indus ial waste holding tank present(yes or no):_ Non- anitary waste discharged to the Title 5 system(yes or no):_ Wat meter readings,if available: Last date of.occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records l'� L� s C. Source of information: �' z ® 6/ `� Was system pumped as part of the inspection(yes or no):_ Ifs,volume pumped: 16 oc.) allons—How was quantity pumped determined? Reason for pumping: TYP 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 compo4ents,date installed(if{mown)and source of information: OL Were sewage odors detected when arriving at the site(yes or no): A- 6 6 I relic 7 of I I OFFICIAL INSPECTION F0101 -NOT FOR VOLUNTARY ASSLSSAIM'S SUBSURFACE SLIVAGE DISPOSAL SYSTEM INSPECTION DORM PART C SYSTEM INFORMATION (continued) rroperiy Address: 28 Crocker Street # 5&6 yannis Owner: Patricaa u toy Dale of Inspection: U U1NG SLNVLII(Iucatc vn site plan) Ucptl► clove grade: Materi Is of eonstn►ction: cast iron _40 I'VC_vtl►er(explain): Distan c (torn private water supply well ur suction lint:_ Con►r tilts(on condition of juutts,vv►ting,evidence of leakage,ct(;.): SL'PTIC TANK:/(locate on site plan) i r Depth below grade: _ Material of construction:_ vncrete metal fibetglass pulyelhylv►e _uthct(explain) _ —' If tank is meal list age:_ Is age ("fit filed b)'a Certificate of Cunq►liance(yes ccrti or nu):_(atiach a copy of ficalc) r ► 1 Dimensions: Sludge depth: -5 ►j ► r Distance (tom top o(slpJgc to bottom of outlet tce or bafllc: lit Sewn thickness: Distance from top of stun►W toll of outlet ice or bafllc: !� ► t Distance born bouvn►of scull'to bottotr►of outlet tee or bafllc: ��, ► Ilow svcre Jiu►cnsivns Jctcnnincd: gy. Cummcnts(oil pumping rceununendativns,inlet and outlet tcc or bafllc ewrditicn, stluctural iniebtity,liquid levels as related to outlet u►vert,evidence of leakage,etc.): GREASE TI ':—(locale oil site plan) Dcl)Ui below adc:_ Material of a struetiun:`concrete_metal Gbesglass_pulycdlyletic _other Dimensions: Scum thickr css: Distance (r In top of scull,to lull of uutict lee or bafllc:_ Distance n►bottom of scum to bullum of uutict tcc or bafllc: Datc of la t pumping: Collul,cn s(on pumping Iccutl,mcndaliuns, inlet and uutict tcc of ba(llc cunditiu:►, situctwal integrity,liquid levels as rclalc lu outicl illvcrl,ct•idcncc of leakage,c1c): 7 Page 8 of I I OFFICIAL 1NSPEC—nON FORM -NOT FOR VOLUNTARY ASSL:SSNILN"1-S SUUSUIt1 ACE SEIVAGE DISPOSAL SYSTEM INSPEC-1-ION FOltNI PART C SYSI M INFORMATION(continued) ProperlyAddress: 2.8 Crocker Street # 5&6 Hyannis Owner `Eatr; ci a M i 1"l lilt Vet Unle of lospeclloo: Y 141-0 TIGHT kNA11 TANK:_(t„,k nnust be pumped at lime of inspectiun)(lucate on site plan) Depth be Material lion:__concrete_metal_fiberglass_pulyeUtylene otltcl(explai,l): Dimtrisi Capacilyallurrs Design fgAlarm prr no):Alarm IcAlann in wurkin urdcrDate of lg: 6 (Jcs ur nu): Cununcnts(condition of alarm and rival st%irchcs,ctc.): UISTIIIBUTION BOX:zorre scut nwsl be opcncdj(locale on site plan) Dcplh of liquid level above oullcl invert: Conunents(note if box is level and Jislributiun to outlets equal,ally evidence of solids cam over,any eviJcuce of leakage imu or out of box,CIO; PUMj%volking (locate on site plan) Pump (Yes or no):_ Alarnr(ycs or no): _Conuon Of pump thautbcr,tundiliuu Of pumps and al1purtcnan(cs,ctc.):_ �I Page 9 of I I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Street # 5&6 Hyannis Owner: Patricia Mulroy Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): r/ (locate on site plan,excavation not required) If SAS not located explain why: Type y. . aching pits,number:leaching chambers,numb_er: 3 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.): CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and c figuration: Depth—top o liquid to inlet invert: Depth of solids layer: Depth of s m layer: Dimensio s of cesspool: Material of construction: Indicati n of groundwater inflow(yes or no): Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY* R�sofc( (locate on site plan) Mat nstruction: Dime sions: De of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page l0 of l l . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Street # 5&6 Hyannis Owner: Pa ri i a MLlrgy Date of Inspection: 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. l - 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: 28 Crocker Street # 5&6 Hyannis Owner. Patricia Mulroy Date:of Inspection: k— SITE EXAM n Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2)0 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the hig g ound water elevation: d. � 91 � g 14 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION R.EC D 200 2004 TITLES T�W OF BARNST HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 28 Crocker Drive #3/4 Hyannis IVAP 3 o6 Owner's Name: Mare Anne Champa PARCEL. ,. O� Owner's Address: pn Rnx R 2 4 `-----� 0 Lor v O�S000.� Date of Inspection: _T�Cie-) UWt� 3 - Name of Inspector:(please print) Wi 1 1 i am _ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number. t5081. 775-8776 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 pursuan7pa ction 15340 of Title 5(310 CMR 15.000). The system: sses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Gam: - ' Date: 1 - The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh-m 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 approxing 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection; _,_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304.exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 1 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,ekhibits.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 1xplain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or _ o structed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with proval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: IThe system required pumping more than 4 times a year due to broken or obrntyded pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rsmovod N explain: Page'3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection: 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. S stem 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 frohl 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 ppni,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. �ther: 3 I Page 4 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 8 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection: D. System Failure Criteria applicable to all systems: You indicate"yes"or"no"to each of the following for all inspections: Yes I;Jo _ \ 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'/,day flow _ Required pumping more Aran 4 times in the last year NOT due.}o 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 I00.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 f et front a private%%mter supply well with no acceptable water quality analysis.(This system passes if llte 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/No)The system fails.1 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 b considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (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 I f you h ve answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"''n Section D above the large system has failed.The owner or operator of any large system considered a sign' ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 4.Th §j stem owner should contact the appropriate regional once of the Department. 4 l Page 5 of I 1 t : OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N :.- Pumping information was provided by the owner,occupant,or Board of Health V Wcre any of the system components pumped out in the previous two weeks? Has the system received normal flows in'the previous two week period? _ --�/}lave 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) —kl— 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 CRR 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: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne C ampa Date of lnspectiom — q _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. ` Number of bedrooms(actual): DESIGN flow based on 310 CNU 15.203(for example: 110 gpd x#of bedrooms):&4 0 Number of current residents: " 1 Does residence have a garbage grinder(yes or no): titJ Is laundry on a separate sewage system(yes or no): 4,o [if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no):kdi� Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4 — 191 , 250 Sump pump(yes or no): 2003 — TTT,-Z 0 0 Last date of occupancy: COMM ERgIAL/1NDUSTRIAL Type of establishment: Design flow6(based on 310 CMR 15.203): LTd Basis of design flow(seats/persons/sgft,etc.): Grease trap`present(yes or no):_ Industrial trap holding tank present(yes or no):_ Non•sanita 7 waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date 4 occupancy/use: OTNEI�(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons•-How was quan ity pumped determined? Reason for,pumping: _ TYP 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/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 known)and source of information: Uri 6 Were sewage odors detected when arriving at the site(yes or no);"d 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOI(MATION(continued) Property Address: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Dote of Inspection: BUILDING SE ER(locate on site plan) Depth below ads. Materials of nstrUctiorr_cast iron _40 PVC other(explain): Distance Go st private grater supply well or suction lint: Comments on condition of juutts,venting,evidence of Icakagc,etc.): SEPTIC TANK:``' (locate on site plan) Depth below grade: 3 1 Material of construction: uncrete metal fiberglass—polyethylene _othci(cxplain) — If lank is meta) list age:— Is age confinned•by a Cenificate of Compliance(yes or no):certificate) —(attach a copy of Dimensions: IV, 14 Sludge depth:_" f r Distance from top of sludge to butlont of oullct Ice or bafnc: _ Scum thickness: ; Distance from top—or-scull, o top of outlet Ice or baffle:_7- Distance frorn bottom of scum to bottom of outlet tee or_ afflle:/Q-L r b llow were dimensions determined: 0 P� A')� - Comments(on pumping recommendations, inlet and o tlet ice or banie condition,structural integrity,liquid levels as related to outlet invert,evidence leakage,c f Icakatc.): ^ & - � c v— GREASE TRAP:_(Joe-"'on site plan) - Dcpdi below&fade: Material of construction,—concrete metal fiberglass youlyethylene—other (explain): — — Dimensions. Scum thickness: Distance Gom top f stunt to top of oudc►Ice or baffle: Distance Gom b lion)of scum to bottom of outlet tee or baffle: Date of last pumping: Conunenls(on pumping recommendations,inlel and outlet tce or baflle conditio:,structural integrity,liquid levels as rclalcd to outlet invert,cridcncc of Icakagc,etc.): 7 Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101 PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Drrtc of lospcctlon:_�� j U� TIGHT or HOLDING TANK: (lank must be pumped at time of inspection)(locate on site plan) Depth below grade Material of constru ion: concrete_metal fiberglass_polyethylene othcr(explaui): Dmtcnsions: Capacity: gallons Design Flow; r gallons/day Alarm present.(y s or no): Alarm level: Alann in working order(),cs or no):` Date of last p4ping: Comments(co dition of,alann and float switches,etc.): DISTRIBUTION BOX: (if present must be opencd)(locate on site plan) Depth of liquid level above outlet invert:-_ Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,ctc.): c) PUMP CHAMBER:/((ycs ocate on site plan) Pumps in working ord or no): _ Alarms in working o4 cr(ycs or no): — Comments(note a edition of pump chamber,condition of pumps and appurtenances,etc.): L 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: 28 Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation*not required) If SAS not located explain why: Type ��eaching pits,number:_ 1/ leaching chambers,number:3 leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): C CESSPOOLS: cesspool must be pumped as part of inspcction)(locate on site plan) Number and confi dration: g - Depth—top of liquid to inlet invert: Depth of/olider. Depth of r: Dimensiospool: Materialsuction: Indicatiodwater inflow(yes or no): Commenondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (10 ate on site plan) ) Materials of c nstruction: Dimensions: Depth of s ids: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 -Crocker Drive #3/4 Hyannis Owner: Mary Anne Champa Date of Inspection: j/—fie g `7 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. - tl � 10 Page a 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Drive #3/4 _Hyannis Owner. Mary An Ch mpa Date;of Inspection: _ Y- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet r Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: S B ¢� 11 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: 28 Crocker . Unit 1 -2 Hyannis Owner's Name: M Galipeau Owner's Address: 34 Crocker St. RECEIVED Date of Inspection: /6 -fS Name of Inspector:(please print) Wi 1 1 i am F_ •Robi nson Sr. AUG.3 12001 Company Name: William E. Robinson Septic Service TOWNoFBARNSTABLE Mailing Address: P O BOX 1089 HEALTH DEPT. Centerville, MA Telephone Number: (508) 775-8776 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 S on 15.340 orTitie 5(310 CMR 15.000). The system: Ies Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: w v� Date: �✓� ""®' ✓ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanhw 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 Crocker St. Unit 1 -2 Hyannis Owner: Gali eau Date of Inspection: R r , - O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.- ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa- d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsour d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the Board of Health. •A'm 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ing that the tank is less than 20 years old is available. ND plain: Observation of sewage backup or break out or high static water level in the distribution box flue to-broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced NDexplain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pasi inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Fgge 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker st. Unit 1 -2 Hyannis Owner: Galipeau Date of Inspection: '7 -I L —U C. urther Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system, is fail' to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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. Sy tem 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 s face water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ `The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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 he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other Uure criteria are triggered.A copy of the analysis must be attached to this form. 3. �ther: F. 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker St.Unit 1 -2 T44za a Owner: Date of Inspection: —d D. System Failure Criteria applicable to all systems: ou must indicate"yes"or"no"to each of the following for all inspections: Y s 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''/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private warm 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/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. Large Systems: o be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 g d. Y u must indicate either"yes"or"no"to each of the following: ( e 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 II of a public water supply well If ou have answered"yes"to any question in Sentinn E the system is considered a significant threat,or answered "' or or of tare stem considered a es m Section D above the large system has faked.Tlae owner vperar any g system gnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 304.The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 Crocker St - Unit 1 -2 Hyannis Owner: Galipeau Date of Inspection: 2—1" 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? y 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 l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Crocker St. Unit 1 -2 Hyannis Owner: Gali eau Date of Inspection: 9/G-6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: l 10 gpd x#of bedrooms): S 6 O Number of current residents: .3 Does residence have a garbage grinder(yes or no): /41 v Is laundry on a separate sewage system(yes or no):/1-0 [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):X Water meter readings,if available(last 2 years usage(gpd)): NA shared water Sump pump(yes or no):k 0 Last date of occupancy: 7-/4-o CO ERCIAL/INDUSTRIAL Type establishment: Design ow(based on 310 CMR 15.203): gpd Basis o design flow(seats/persons/sgft,etc.): Grease ap present(yes or no): Industr al waste holding tank present(yes or no): Non-s itary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last ate of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records p e Source of information: 1 ey `3 '7 9 `t1 I "f �' Was system pumped as part of the inspection(yes or no):,1�p If yes,volume pumped:_gallons--How was quantity pumped determined? Reason/for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool �eha,red y system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contact(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 sourc of information: /mac: 8" 601,11 2 ' Were sewage odors detected when arriving at the site(yes or no): d 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker St_ Unitl -2 Hyannis Owner: Ga 1 i =Pau Date of Inspection: -7"/4-a BUILDI SEWER(locate on site plan) Depth belo grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance fr m private water supply well or suction line: Comment (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:zoocate on site plan) i Depth below grade: �- / 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: L Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: `I Scum thickness: ®-/ J Distance from top of scum to top of outlet tee or baffle:_7- Distance from bottom of scum to bottom of outlet tee or baffle: 1,:s How were dimensions determined: O p`" 1" Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): ` GREA TRAP:_(locate on site plan) Depth bel w grade: Material o construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimension : Scum thic ess: Distance in top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comment (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate o outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker St. Unit 1 -2 Hyannis Owner: Galineau Date of Inspection: °7 TIGH or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth bel w grade: Material o construction: concrete metal fiberglass_polyethylene other(explain): Dimension Capacity: allons Design Flo gallons'day Alarm pre ent(yes or no): Alarm lev 1: Alarm in working order(yes or no): Date c f 1 t pumping: Comme s(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Xifpresent 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.): PU CHAMBER: (locate on site plan) Pump in working order(yes or no): Alarms in working order(yes or no): Comn ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 page 9of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker St- Unit 1 -2 Hyannis Owner: Gal, eau Date of Inspection: ')-! SOIL ABSORPTION SYSTEM(SAS):u (locate on site plan,excavation not required) If SAS not located explain why: .type ; aching pits,number:_ leaching chambers,number: 3 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.): CESS OOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number nd configuration: Depth—t of liquid to inlet invert: Depth of s lids layer: Depth of s um layer: Dimension of cesspool: Materials o construction: Indication o groundwater inflow(yes or no): Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials f construction: Dimensio s: Depth of olids: Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 1 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker Gt Unit 1 -2 Hyannis Owner: Gal i Peate, Date of Inspection: 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. 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: 28 Crocker St. Unit 1 -2 --Hyannis Owner- Gali eau Date of Inspection: 77 va , SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 1 0 feet Please indicate(check)all methods used to determine the high ground water elevation: 4 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: Z;/S Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the igh ground water elevation: y , 11 COMMONWEALTH OF MASSACHUSETTS IbY 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 a. Property Address: 28 Crocker �S:L—. • Unit 5-6 Hyannis Owner's Name: M Galipeau Owner's Address: 34 rrnnk,-r St Date of Inspection: RECEIVED Name of Inspector: (please print) Wi 1 1 i am E_ • Robinson Sr. AUG 31 200, Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 TOWN OF gARNST ABLE Centerville, MA HEATH DEPT. Telephone Number: ( 5 0 8 ) 7 7 5-8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: lv an-J-s 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. 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker St. Unit 5-6 Hyannis Owner: Gal eau Date of Inspection: - s 0- Inspection Su mary. Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa' d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist" g tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ting that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 lanes a year due to broken or obstructed pipe(s).The system will pas inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: _Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:. 28 Crocker St. Hyannis Owner: Ga ipeau Date of Inspection: —/ '-6 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 fai ' g 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 ystem 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. stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 urface 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 froni 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: 3 I Page 4 of 11 ' - r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 Crocker St. Unit 5-6 Hyannis Owner: Gaii peau Date of Inspection: "G D. ys em Failure Criteria applicable to all systems: You ust indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You m st indicate either"yes"or"no"to each of the following: (The fo lowing criteria apply to large systems in addition to the criteria above) yes n 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 yo 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 famed.The owner or operator of any Inge system considered a signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 .The system owner should contact the appropriate regional office of the Department. 4 -, g--Pa e 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 Crocker St. yannis Owner: Galipeau Date of Inspection: "7 'd Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes 11 o • 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? THas the system received normal flows in the previous two week period? _ v 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) J Was the facility or dwelling inspected for signs of sewage back up? C/ 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? V/ _ 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 o _ 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 I 1 • r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Crocker St. Hyannis Owner: Gali eau Date of Inspection: 7-16-61 FLOW CONDITIONS RESIDENTIAL Ll Number of bedrooms(design):_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): SSO Number of current residents:V Does residence have a garbage grinder(yes or no):j1�4 Is laundry on a separate sewage system(yes or no):A d [if yes separate inspection required] Laundry system inspected(yes or no)-AV Seasonal use:(yes or no): A- Water meter readings,if available(last 2 years usage(gpd)):NA shared water Sump pump(yes or no): b4O Last date of occupancy: T/L—O COMjs RCIAL/INDUSTRIAL Type tabIishment: Design fl w(based on 310 CMR 15.203): gpd BasIER(describe): gn flow(seats/persons/sgft,etc.): Greresent(yes or no):_ Indste holding tank present(yes or no): Nonwaste discharged to the Title 5 system(yes or no): Wareadings,if available: Lasoccupancy/use: OT GENERAL INFORMATION Pumping Records Source of information: 10/ 1 9 19 9 q o*,G 6 4 o`I 6-0'° Was system pumped as part of the inspection(yes or no):/L d If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPTAOF 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: C'as /`aV1 - Were sewage odors detected when arriving at the site(yes or no): d0 6 i f Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Crocker St. Unit 5-6 yannis Owner: Galipeau Date of Inspection: BUI ING SEWER(locate on site plan) Depth low grade: Materi s of construction:_cast iron _40 PVC_other(explain): Distan a from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: `_' (locate on site plan) Depth below grade: 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) d 6 y 0 - Dimensions: G `- & S L Sludge depth: 0 - 3 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I-3 , Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: / X How were dimensions determined: ® IPc��- ''" .-� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): a / po di jbwlC � �� J ►.. Y �/4' GREA E TRAP:_(locate on site plan) Depth b low grade: Materia of construction:_concrete_metal_fiberglass polyethylene_other (expla' ): Dimen ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: .Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relat d 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: 28 Crocker St. Hyannis Owner: Gali eau Date of Inspection: -1-/ -o 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: v (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Ll 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.): P P CHAMBER: (locate on site plan) Pu ps in working order(yes or no): Al s in working order(yes or no): C mments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9of11 5 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address. 28 Crocker St Unit 5-6 Hyannis Owner: Galipeau Date of Inspection: '7 --'-/—O / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:_ ✓leaching chambers,number: 3 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.): 3 ~ /�a-o S jo��y �� G dG�.-rr .� C— A- ,;,i„i a M 9 9 CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numbe and configuration: Depth— op of liquid to inlet invert: Depth of olids layer: Depth of um layer: Dimensio of cesspool: Materials o construction: Indication groundwater inflow(yes or no): Comments iote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials construction: Dimensio s: Depth of olids: Comme s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I 17, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESE WAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION(continued) Property Address: 28 Crocker St. Unit 5-6 HyanniG Owner: u Date of Inspection: 17 o 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. i lag ey �n r � L 9� 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: 28 Crocker St. Unit 5-6 Hyannis Owner: Gali eau Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water J_b 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: bserved site(abutting property/observation hole within 150 feet of SAS) ,.-"Checked with local Board of Health-explain: 6 J-Ir zvgg S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation AZ �lS 1In +D 4L�3 U7a/G3 / K' 11 TOWN OF BARNSTABLE Al LCkCATIC)N 'Ty'aNaviS _ SEWAGE # VILLAGE 2-1 ' C1 OCICC- 17 P—i Q ASSESSOR'S MAP & LOT,3060-0'a3V'0 l ii INSTALLER'S NAME&PHONE NO. W& C- J?Xhc t SON 775=9'77fo SEPTIC TANK CAPACITY i LEACHING FACILITY: (type) _ L:! t (�S (size) NO.OF BEDROOMS BUILDER OR OWNER. PERMTTDATE: 12LIi -3 9 9 COMPLIANCE DATE: 961 2000 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility, (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 09 , 0 s � h � �G Fee $�o / No. ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for nigogal *pgtem Congtruction Permit Application for a Permit to Co t )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 2 7 e an A v e . , Hyari 3D%ner's Name,Address and Tel.No. Units 3 and. 4 C'v-0c1kx,--- d)-lw Monique uallipeau Assessor'sMap/Parcel a! 030 —aoc -t 00 A P 0 Box 553, Hyanriisport 14sXm er'sg7e,ddr,an Tel.N e pt i c Service Designer's Name,Address and Tel.No. WWP 0 BLB``oxKK1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) New Title e—5 leanh -,�r,-t P m. D-box and. 3 leach chambers, ( Heauy d.uty) with stone all around.. 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 is by this ar of Health.• Signed Date Application Approved by Date /1- Application Disapproved for the following reasons 0 Permit No. Date Issued .No. / � / `. Fee _ / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION.-TOWN OF�BARNSTABLE., MASSACHUSETTS ZippYication for Migon'l *pMem' Con.5truction,permit Application for a Permit to Co ct )Repair( )Upgrade( )Abandon'( ) ❑Comflete System ❑Individual Components Location Address or Lot No. 2 7 e an Ave . Hyahr miner's Name,Address and Tel.No. Units 3 and 4 �' -0Ck V�trt Monique Gallipeau w sF 'Assessors Map/Parcel ._ • 3dG -030 -hoc f po P 0 Box 553, Hyannisport In taller' Te d ss and Tel. Designer's Name,Address and Tel.No. vim. . to` isoneptic Service -• P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) t Other Fixtures ,l Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S� d Nature of Repairs or Alterations(Answer when applicable) New T itle-ri leach so etem'. D-box and 3 leach chambers, ( H '°' :r d.utY) with stone all around . Date lastspected: 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 issue by thi�arbf lth. q Signed t �^ Date Application Approved by c , Date Application Disapproved for the following reasons Permit No. Date Issued ----------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS nGallipeau BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at -2.7_0 0.C_e-'U3,,,, Ke_ , Hyannis -? F C►-r c has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `� yC dated Installer Wm. P. R n h j;ng on Sr. Designer _ A_ The issuance of this1permit shall not be construed as a guarantee that the sy �. will function as d ignef r : Date 121 1 Inspector _ '� i ,� �7, 1/l�� v v �_ W i ---—�-------------------------- `� V r— No. Fee THE COMMONWEALTH OF MASSACHUSETTS } PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Gallipeau M gpogaf *pztem (Construction Permit Permission is herebyranted to Construct Repair X g ( ) p ( )Upgrade( )Abandon( ) System located at ? 0...8�ear�--�.v.�. , Hyannis 2 t, C 4DY Ca..P , , ,a— 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. Q r! q q F Date: _/J• l Z-— / 3�/ / Approved by U6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) l W i l l iatn E . R ob ins'on,`�rhereby certify that the application for disposal works construction permit signed by me dated —�� / concerning the property located at 270 n c,P a n Ave r—��}� meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. Y There are no wetlands within 100 feet of the proposed septic system ` 1ph IS a ("h I TOWN OF BARNSTABLE LOCATION N iqN S SEWAGE # % S y 0 10(0.103a-cam VILLAGE � Crc J.0 •rt D aAi ASSESSOR'S MAP &LOTS INSTALLER'S NAME&PHONE NO. lr} ��S� Sc-��;c 775% 776 IC TANK CAPACITY SEPT i�i'Z.J �. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS j . ! BUILDER OR OWNER PERMTTDATE: ��- 3 COMPLIANCE DATE:_ I mo+ �Q0LJ Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet A within 300 feet of leaching facility) Furnished by o p O Or i i No. .. ....._ --- ©'� © A�> . Fxs. ........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................ ........................O F........................................................................................... ApplirFation for Dispas al Worko Tonotrur#iun ami# Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System at: 1)( -, v.Z 1 ..............C K0 C K ..... �! j:....t........1. . .. .�-�0.~--.... ---•--------------------........--•------ i ' Location-Address or Lot No. ........�-ra�Ja-•--.C-A-L,I-P.:G'�4------------------------------------------ ..........�.__�,�:G _t�_ T=--•---....�eE.Igcml ...Z!ac;;c,. Owner Address w C s` .:...... C s &Aa gar►.................. ------------------------------•--------•-•----------......------------...------......---..... Installer Address Type of Building Size Lot....1SA�G22___:__Sq. feet Dwelling—* No. of Bedrooms_._.....L..............................Expansion Attic ( ) Garbage Grinder (mt) Other—Type of Building ...CAP.C>.......... No. of persons........ ..._............ Showers (I — Cafeteria ( ) Q' Other fixtures ----------------------------------------------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. ` Seepage Pit No------_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date--------------------------------------- Test Pit No. 1................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........................ M - ----------•----------------------- -----•----------------------.--------------------•--------------------------- --- ODescription of Soil-------- _��.!•--�F}r.9�.....------•--------------------------------------------------•-----------------------------------._.............. x w --------------------------------------------------------------------------------------•---------------------------------------------------......-------------------------------------------------------- V 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 iITA IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation untikgrt'Ntificate of Compliance has been issued by the board of health. :6 — 2 �,S �--"� D to Application Appro ed By.-_---. Date Application Disapproved o e o owing re ns----------------•----•------•--------•-------------------------•--------------------------------•-------....----- ----------------•--•••••.....----••-•------•••-•...---------.......-------------•-...--------•---•-----...-------------------------•-••-••--••-•...--------•-•---••-••---•--------•------- Date PermitNo....................................................... Issued....................................................... Date No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF Appliration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ..............C.5 a�'r............................. ...............................................V.................................................. Location-Address or Lot No. +L �. ............................................ ..........C-g ...........so— Owner Address ...................C.PWC......... ,t C.110LN, ................... .................................................................................................. Address Type of Building Size Lot...MaepiL-----.'Sq. feet Dwelling—No. of Bedrooms........2-01---"I',"",-,--------Expansion Attic Garbage Grinder (0% Other—Typepf_Building, ..-C-AIP -........ No. of persons:._ Showers howers Cafeteria Otherfixtures ...................................................................................................... --------------------- ---------- Design ...............gallons per person per day. Total daily flow........ gallons. ..................... ------------------------------------ 9 Septic Tank-Liquid ca i Ilons Length________________ Width_..____..__._.._ Diameter._.-.._.._-..._. Depth______..____._.. capacity............ga Disposal Trench No. .........*---------- Width................._.. Total Length.............._..... Total leaching 4p;a,-------------------sq. ft. Seepage Pit No--------------------- Diameter---,............... Depth below inlet,................... Total leachl ng area...............;'..Sq. ft. Z Other Distribution box Dosing tank Percolation Test Results PerfoXped%by......................................... ..................... Date....................*---------4 ---------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 1-4 44 Test Pit No. 2................minutes per inch Depth of Test Pit___...........__._.. Depth to ground water------------------------ .................... 0 ----------- r-;4--=-S' -----------*--------11-11------ --------- ------------------ - Descriptionof Soi...........................4............................................................................................................................................ ....................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .................................................................................................... ........................................................................................v.......... 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 undersigned further agrees not to place the system in operation unt*,:�,tificate of Compliance has been issued by the board of health. F K 16 - 2- S-S ................. ................................ D t Application Appro�ed By ...........f:a y------ .................................. ---------57.7.!� f........ ........ Date Application Disapproved;�- a lowing ons:........................................................................................ ...................... .................................................................................................................................................................................................._----- Date PermitNo......................................................... IssuedL............................ ----------=------------- j Date max' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... THIS JS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.........................6r&A-0-z.........V-tpaj-V:a; ....—...# z -----"----------------------...................................... --- .......**.......*........40( 1- X Installer at . � ------- V has been installed in accordance with the provisions of TITLE '"-5 of The State Sanitary Code as described in the application for.Disposal Works Construction Permit No......................................... dated-----------77n ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANI E THAT THE SYSTEM WILL4 FUNCTION SATISFACTORY. -7� 04 DATE..... 4 Inspector:.._.__............................................. Insp o .............................. --------------------------- ------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... ........................ FEE...: . ........ Permissionis hereby granted............... ............................................................................ to Construct or Repair an J114vidual Sew,,age Disposal System atNo...... ....... ...... ........- Street as shown on the application for Disposal Works Construction Permit No Dated..��. -4 1:3.�............ ...................................... -------.. ............................................................... Board of health DATE.....---5... ...... .......... FORM 1255 A. M. SULKIN, INC.. BOSTON Ste. `., C .c.s IN TOWN)F Be�ll STABLE LOCATION Z24 O C.A� SEWAGE# VILLAGE ��y�'!'�N-e o:. ASSESSOR'S MAP&PARCEL 'OI, C-� 0009 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BPTE: OMS OWNER GL1Wet 4� PERMIT 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 TOWN OF B STA&6�T LOCATION C*& SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL,30G— Q50 —0D,3 INSTALLER'S NAME&PHONE NO. NI/ oac SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ' (size) NO.OF BEDROOMS �{D OWNER C OO PERMIT DATE: 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 ..i - � 1p__ ...31.d TOWN OF STAB LOCATION os g�G e SEWAGE# VILLAGE e—s ASSESSOR'S MAP&PARCEIJO"4—G.30" 00'2) INSTALLER'S NAME&PHONE NO. V SEPTIC TANK CAPACITY 00 E LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER ifp• -4,APa PERMIT DATE: 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 41,� Joe TOWN OF ARNSTAB LOCATION -*? O C/!O L' �Q�� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL,Xyg 090-00)= INSTALLER'S AME&PHONE NO. �1.J] 4� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) size NO.OF BED OOMS OWNER PERMIT DATE: 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 1 t/ ) % li 29 14 Lc .f c 30I.0 yam'' 5TX — (n 5" 57 STiC ` 'fir:• 4 LL y, SET = /5' SrT JZ' d / T-lLA1e SSA ,`v 30 Il( ep cf� 31.0 r f rt D./3 I n) �3 W Y 0 C)N _ a � loot/ cv � 3►.S �` .31.E ---��4 �' t L • fc) FJUQ e N LD � I Cp�.9 2 Sk'FTCH POIN OF l OA) 1 N -6 5 ' R TJ 1J 1�{ � i W) �: Qu�i,o e a 4w _ BL/r�lj t/.J F C?j S�lD�Ji) U/'7 Gl [)�.7.•'! 4i 1` /!�/i,J +-/yV/)/)//sf IYI�i, T'c�✓' /t//ar y Al. 0/ /6fh 1955. RL�eorr/c�•,;j' ��-) t/)e Z',,-�.� .,f:.)�!aic;, ,�,;'r ;ffr a� ,� Ate: Li/.:;�- t �ili:.`.'.fr)tc'i~r_'c D� e1!�' Book /3tv DG ';i'. Perc. A'�; / � ) T�/iT/-;' �IGlii"/�/T ::xi/'/75:�-L77�::,�z; ;��c: ,/r';.-.../t )�• IF f r , U, F.y.FiJ L c�I {