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HomeMy WebLinkAbout0006 CROOKED POND ROAD - Health 6 CROOKED POND ROAD, HYANNIS A= T7 i I i o o ' Town of Barnstable Barnstable NAM Regulatory Services Department Q p .19. Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3357 May 18, 2016 Mr&Mrs Scott Fraziel 45 Dupaul Street#3 Southbridge, MA 01550 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 6 Crooked Pond Road, Hyannis, MA was last inspected on April 14, 2016 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Rotted distribution-box needs to be replaced • Tank leaking: Outlet baffle broken; needs to be repaired. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to'repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER O HE BOARD OF HEALTH t o_ Thomas McKean, R.S., CHO Agent of the Board of Health a-� Q:\SEPTIC\Conditionally Passes Ltr\6 Crooked Pond Rd Hy apri12016.doc �� ,. V_ I .. _ y i c __--- ,• � �, � � �_ � � �_j � J I i i,� �. , Barnstable i Town of Barnstable :. Regulatory p Services Department Q D snsnrsras�e, � m Public Health Division 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2848 1643 October 3, 2016 Dmetry and Irene Zinov, Trustees F 76 Thread Needle Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 RE: 102 Iyannough Road, Hyannis Map/Parcel 328-152-OOA through -OON The septic system located at 102 Iyannough Road, Hyannis MA was last inspected on September 27,2016,by Donna Miorandi, Health Inspector for the Town of Barnstable. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. You are ordered to pump the septic system within the next twenty-four (24) hours. It shall be pumped on a daily basis until the required repairs/replacement has been accomplished to prevent any further backup of sewage into rental units. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\102 Iyannough Rd Hy James-Stephn Sep2016.doc a Town of Barnstable . � L►xrrsrnai.E, p �9 ,� Regulatory Services Department rea rAP't" Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS Town Code 360-44 and Title V: 310 CMR 15.000 An"X"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe... ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution`box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER C f C 1'n SQ 1 i\ _.. , ✓l IL. Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc - Parcel Detail Page 1 of 3 t 1 T KL- v t+s5 } =" -lex-0 eel Logged In As: Parcel Detail Monday,May 2 2016 Parcel Lookup Parcel Info Parcel ID29911�151 � ' Developer(LOT 1 BLOCK 6 I Lot Location(6 CROOKED POND ROAD ���� �t Pri Frontage115 Sec Road iCOUNTY SEAT STREET .... L) sec Frontage 113 m TM m I Village HYANNIS Fire DistrictHYANNIS I ' 0 386 Town sewer exists at this address#ND NO �.-�.,�.,o.......f Road Index� Asbuilt Septic Scan: Interactive rm 2911511 Map , Owner Info Owner�FRAZEL, SCOTT A& LAMPERT, ELIZABETH M I Co-owner � � streetl 45 DUPAUL ST.,#3 street2 city SOUTHBRIDGE _ state MAM zip 101550 Country _ -- Land Info Acres�;E_7 use TSingle Fam MDL-01 Zoning }RB I Nghbd#0104 Topography Level Road (,Paved Utilities I eptic,Gas,Public Water I Location Construction Info Building 1 of 1 Year Roof'" Ext Built j-196-3-ijstruct(Gable/Hip I wall Wood Shingle Living 1104 "`-1 Roof AC GIs/ f None Area^ Cover Typepe fj .,,�.�,,.m. a t �' style Raised Ranch wall fDrywall Bed 3 Bedrooms zww[K Rooms a Model Residential ( Floor Carpet R oms?1 Full-1 Half�� " Heat�' Total $ Grade lAVerage Type Hot Water f Rooms F6 ROOMS Stories�11$tOfy l Heat lCiaSW" "' _"`��Found �oured Conc. Fuel ation: r Gross J2352 , Area _T Permit History 11 Issue Date Purpose Permit# Amount Insp Date Comments http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22704 5/2/2016 Apr 16,2016 16:03 Jim The Inspector Man 5085349919 page 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '4 6 Crooked Pond Road Property Address p.a Fannie Mae a Owner Owner's Name information is required for every _Hyannis ✓ MA 02601 4-14-16 page. City/Town State Zip Code Date of ln'spectlon tp Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ('I# on the computer, 1/6d� J ����{OFt'11 use only the tab .�` "'"" •. q�'� 1. Inspector: key to move your ?;• ',yG cursor-do not James D.Sears =: JAMES :m kee the return Name of Inspector = Y• pt'Na Enterprises, LLC ' e5 .Coo mpanany Name 0-IF 153 Commercial Street Company Address I Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a yLe�� 4-16-16 V spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 h Apr' 16 2016 16:03 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any Failure criteria not evaluated are indicated below. Comments: Conn Pass-tank leaking D Box. House vacant at tme of inspection. The system is a 1000 Gal. Tank D Box old pit and four chambers. i B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by ' � the Board of Health,will pass. ? Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. i The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of. Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): i i [Sins•3f13 Title 5Official Inspection form:Subsurface Sewage.Disposal System•Page 2 of 17 Apr 16 2016 16:03 Jim The Inspector Man 5085349919 page 20 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road .Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not.operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): D Box need to replaced. Tank leaking. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: El 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 mannerwhich will protect public health; safety and the environment: •❑ Cesspool or privy is within 50 Beet of a surface water ❑ Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh 15ins 3113 Title 5 Official Inspection Form:Subsurface SeArage Disposal System•Page 3 of 17 Apr. 16 , 2016 16:04 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-1446 page. CitytTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet.of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`s. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in ve*sj=l is less than 6° below invert or available volume is less. than '/2 day flow P 1`',(-,4 E 4 efrtiN G . 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of W Apr 16 2016 16:05 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name Information Is required for every Hyannis MA 02601 4-14-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This . system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Ell Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section.D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3A3 Title 6 Orfidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Apr 16 • 2016 16:05 Jim The Inspector Man 5085349919 page 23 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 6 Crooked Pond Road Property Address Fannie Mae Owner Owners Name information is required for every Hyannis MA 02601 4-14-16 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no' as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® LWere any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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 CM 15.302(5)] D. System Information Residential Flaw Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 330_ s . 1 t5ine•3113 Title 5 Official Inspection Form:Suhsuraoe Sewage Disposal System•Page 6 of 17 Apr 16 2016 16:05 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form r a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box old pit and four chambers. lT {�, Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014-28,500Gal' g ( y g (gP ))' 2015-3,750 Gal's Detail: Note : Water turned off. Aug 26-2015 Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ ,No Non-sanitary waste discharged to the Title 5 system? ❑ Yes, ❑ No Water meter readings, if available: 15ins•3113 .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Apr 16 2016 16:06 Jim The Inspector Man 5085349919 page 25 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is y required for every Hyannis MA . 02601 4-14-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 3 ® Septic tank, distribution box, soil absorption system ❑ Single cesspool i ❑ Overflow cesspool ❑ Privy i ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ In technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑' Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): i 15ins-3113 - Title 5 Ofnclal Inspection Form:Subsurface 66"ge Disposal S stem-y Page 8 of 17 Apr,16 2016 16:06 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form NNW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owners Name information is required for every Hyannis MA 02601 4-14-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank D Box and pit NA /Chambers 2000 permit#2000-492 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 Gal. Precast H-10 Dimensions: Slu611 dge depth: t5ins•3113 Tltle 50Kcial Inspection Farm:Subsurface Sewage Disposal System-Page 9 of w Apr 16 . 2016 16:06 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 1 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Note : Tank leaking. Tank and outlet cover at 1' below grade w/inlet cover at grade. inlet baffle. Outlet baffle broken. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 1 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5lns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Apr, 16 , 2016 16:07 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. Citylrowm State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day ; Alarm present: ❑ Yes ❑ No Alarm level:. Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 1 "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No N 15irt3•3.113 Title 6 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17 Apr 16, 2016 16:07 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owners Name information is y required for every Hyannis MA 02601 4-14-16 page. Cityrrown State Zip Code Dale of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 12" x 16"- 18" below grade w/two lines out. Box is in Bad shape Need to replace D Box 0 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes: ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage' P Disposal System•Page 12 of 17 Apr 16, 2016 16:07 Jim The Inspector Man 5085349919 page ,30 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a old 1000 Gal. Precast pit. Pit at 1'below grade- dry clean wall's and stone in holes. Also leaching has four chambers w/stone 32'x10'. Envird chambers are dry and clean. Cked out w/camera. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration { i Depth—top of liquid to inlet invert - a Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15in6.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Apr 16. 2016 16:07 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts . _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a i 8 t5ins•3l13 s Title 5 Official Irspection Form:Subsurface Sewage Disposal System•page 14 of 17 Apr 16. 2016 16:08 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owners Name information is required for every Hyannis MA 02601 4-14-16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately P,"v 13 s�a7 O t i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 j 7 Apr 16. 2016 16:08 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every y H annis MA 02601 4-14-16 page. City/Town State Zip Code Date of"lnspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells O IL' Estimated depth to high ground water: 1'+ feet Please indicate all methods used to determine the high ground water elevation: .. ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of.SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain:. i You must describe how you established the high ground water elevation: Auger T.H.11' no G.W.. Bottom of pit at 7' below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•3113 Title 5 Official Inspection Form:Sutmurface Sewage Disposal System•Page 15 of 17 , Apr 16. 2016 16:08 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Crooked Pond Road Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached,in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 17 x. TOWN OF BARNSTABLE -L �,` 1 LOCATION(P CrOOY�� ��OC�CA P d - SEWAGE# 6' t0p & VILLAGE" AUW'yS MAP&PARCEL INSTALLER'S NAME&PHONEINO. (� jakk(1 SEPTIC TA1gK.CAPACITYp (Ctn1L_and '�3ou LEACHING FACILITY:(type),' (size) ��3 M NO.OF BEDROOMS 3 . OWNER Hh PERMIT DATE: ; ' -,COMPLIANCE DATE: f 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 NO feet of leaching facility) Feet FURNISHED BY w � � cow go-No 7?0 J% cl n V 4 '60�- •� r No. (✓� ���� C2?� 15-1 Fee /0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitation for Disposal Opstem (Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade(V Abandon( ) ❑Complete System ❑Individual Components Locatio Address or Lot No. C� LiP� on Owner' Name,Address,and Tel.No. �r ,� 7(9'��O 2 Pig /o l n n��. ! � �iVn Assessor' ap/Pazce f— f s Instal is Name, ddress,and Tel. o. Designer's Name,Address,and Tel.No. � L en s Y'Y�+�:143 Pau &_ u Type of Building: 2 Dwelling No.of Bedrooms v,^, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building t'L,St d(f'I �nj -- No.of Persons -j' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required), Z a gpd Design flow provided gpd Plan Date 'tj�� /(!' Number of sheets Revision Date Title Size of Septic Tank XM rj Type of S.A.S. Description of Soil 0 ,2%n/1 v1 Nature of Repairs or Alterations(Answer when applicable)`/;90 IG ( (S I0 _P—b �` tjL1 cew1 �' P� 1�.1 t _ /5-w 6c-Z Sri n 1�-. D 63 -gD X Date last inspected: #, q 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 B of Health. Si ed Date V Application Approved by Date l0 Application Disapproved by Date for the following reasons Permit No. �9 ^� Date Issued 0 _- -_ —------ St i i No. (7?/G ^/ `� PC 9( l (J'l / V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'j PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application fOr ;.D18tlosaY *pstem Construction Permit, Application for a Permit to Construct( ) Repair Upgrade( Abandon( ) []Complete System ❑Individual Components (� ncatio a. Address or Lot No.�.. C(-6 v V-,pA K7 Owner's Name,Address,and Tel.No. Sw-.116-,-250 Assessor's-'ap/Parce M a�f- 1 ( - /p j Instal is Name,' ddress,and Tel.No. Designer's Name,Address,and Tel.No. A J chi Type of Building: Dwelling No.of Bedrooms J,, /� . (� Lot Size I sq.ft. Garbage Grinder( ) Other Type of Building d'OS(L� n--�l` No.of Persons�(�Cra r7 4- 'Showers( ) Cafeteria( ) Other Fixtures -' Design Flow(min.reequired)p 'j 3 D gpd Design flow provided gpd / Plan Date ry`l q- Number of sheets Revision Date ✓ Title n Size of Septic Tank `�,/,t_1t Type of S.A.S. Description of Soil' Nature of Repairs or Alterations(Answer when applicable)`']�V !L Id P-D6)( f n i lv D /S I�D )C Date last inspected: G— P !, � '7 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 Boar'of Health. / Si ed -� /�/ .ii 4/t Date V Application Approved by w4 Date to l0 �p Application Disapproved by Date for the following reasons Permit No. O l ��p Date Issued -------------------------------------------- - ----------- ______.__--_- -- - ` THE COMMONWEALTH OF MASSACHUSETTS ` Pvuj Se�� - BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(vim)' Upgraded( ) v Abandoned( )by at &trP has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N .. /� ' dated p p y � Ah G Installer 6 Designer , #bedrooms A" Approved design flow ' , gpd The issuance of t y e it shall not be construed as a guarantee that the system willpfunctio �s design 1( Date �1 � /(� Inspector , ------------------------------ -------------------------------------------------------------------------------------a-- -------- No. Q� ' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) n Upgrade( ) Abandon( ) / System located at r Y G'o k `Pn� I D'h 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 in be co' pleted within three years of the date of this ermit. Date � b 1�1 6 Approved by 6 ` C-` � TOWN OF BARNST LE LOCATION C R 26 L d Pdnid 11� SEWAGE # VILLAGE �S"1 RA)IV 1_5 ASSESSOR'S MAP & LOT N-STALLER'S NAME&PHONE NO. T n 0ip I w SEPTIC TANK CAPACITY k O O LEACHING FACILITY: (type) 13 O iae) 1/.11Lo NO.OF BEDROOMS BUILDER OR OWNE e PERMTTDATE: 19WCOMPLIANCE DATE IrVbn : Separation Distance Between the: T Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Z Feet Private Water Supply.Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) G Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ior- ag�i ng ilityM Feet Furnished by /`� _y �� �� � � � � � � �t t� - lr' 4 ,� � � ��,. : E ,� � . ��., �z .. � � �� rt j C � � �' � O C�3 X 1 tii� ., � � ��_� �. ;n'• 4 r n ;�'• .. I No. `�./J.O%> '*^ '1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Mtgooar *pztem Construction Permit Application for a Permit to Construct( )Repair 1<1 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No � Owner's N_f��and Tel Assessor's Map ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 P Md-L 7 5- 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 4O o a Type of S.A.S. eb���.Z Description of Soil v 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 o tt e 5 o the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this B d of lth Signed l - - 4., Date Application Approved by Date Application Disapproved for the follo 'ng reasons Permit No. .'IVew — V Q aL Date Issued -P/Ol! Fee No, d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _1 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for 33igool *p!6tem Con5truction.Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) El Complete System El Individual Components Lotion Address or t N Owner's N�zne7s an 1� No. t y �r Assessor's Map/PazcelMP 1p, 00 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ��4 Type of S.A.S. 60 /- Description of Soil Nature of Repairs or Alterations(Answer when applicable) f n 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 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 d oal� -y , Signed y —�"`_ Date4O,ZiG7 Application Approved by Date Application Disapproved for the following reasons Permit No. .00 - �..9 Z Date Issued . --°------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(,V )Upgraded( ) Abandoned C )by l" mo ) ✓U at has been constructed in accordance with the provision f itle 5 apd the for isposal System Construction Permit cO — Y? - dated Installer J o''� Designer r1,4 G The issuance of this pe"v� ft shall not be -nstrued as a guarantee that the ys eilt�wii/hfunctio}�as designed; a �` Date 5 1 Inspector 11 d ,'f A i!i't Pat �kl ' -----(,f—q--------------------------------- No.OE Fe.— r--' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigool *p.5tem Construction Permit Permission is hereby g anted p Constru on t( /'�Rep )Upgrade( )Aband ) System located at ���1-� 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. Date: Approved by . 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL V WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS). I, , hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at � �✓� meets all of the following criteria: • This 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. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) _ B) G.W.Elevation -d +the MAX. High G.W.Adjustment.c�. DIFFEREN BETWEEN A and B l 3 SIGNED : DATE: Y' [Please Sketch pr osed plan of system on back]'-- NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert .,,. t. p� N � I i L" TOWN OF BARNST LE LOCATION Pd VJ IR SEWAGE # o - `6L CROO VILLAGE �"S" R� S ASSESSOR'S MAP &LOT — INSTALLER'S NAME&PHONE NO. Z y 121 -4) SEPTIC:TANK CAPACITY > LEACHING FACILITY: (type) NO.OF BEDROOMS_.; BUILDER OR OWNER; {, PERMITDATE: COMPLIANCE DATE: ? ` Separation Distance Between the: j. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 2 S Feet 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 within 306 feet Feet { Furnished by pi / R? 7D �, v 12o Commonwealth of Massachusetts JU Cfl� Executive of Environmental Affairs z 2 Department of Environmental Protection c� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ��Crooked Pond R oad�Hyannis MM a. Address of Owner: Dana Neale (if different) 53 East Main Street. Mystic, CT 06355 Date of Inspection: 07/16/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o B ox 2384 - M ashpee M a 02649. Tel : (508)4771420 CERTIFICATION- STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system 4 Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature. /Lj ( Date: 07/18/96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ,a Property Address: 6 Crooked Pond Road. Hyannis,M a. Owners : D. Neale Date of Inspection : 07/16/96 INSPECTION SUMMARY: Check A, B,C, or D A)SYSTEM PASSES: K I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303.Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or N D). Describe basis of determination in all instances. If"not determinated", explain why not. --- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ----- broken pipe(s) are replaced ----- obstruction is removed --- distribution box is levelled or replaced ---- The system required pumping more than four tines 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 I ----- obstruction is removed G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 6 Crooked Pond Road. Hyannis, Ma. Owner: D. Neale. Date of Inspection : 07/16/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IFAPPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PART A CERTIFICATION (continued) ,o Property Address: 6 Crooked Pond Road. Hyannis, Ma Owner: D. Neale Date of Inspection 07/16/96 D)SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a public well. --- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PECTION FORM CERTIFICATION (continued) Property Address: 6 Crooked Pond Road. Hyannis Owner: D. Neale Ma. Date of inspection: 07/16/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition The design flog of system is 0.000 trap ka the criteria above: is a significant threat to gpd or greater Lar e System Rublic health and safety and the eni mend becau thestem one or mare of the following conditions exist use ... the system is within 400 feet of a surface drinking --- the system is within 2I)0 feet of a tributaryt water supply the system is located in a nitro e o a surface drinking water.supply Area -I PA or a 9 n sensitive area(Interim Wellhead Protection mapped Zone II of a Rublic water supply well. The owner or operator of any such system shall brie ante with the groundwater treatment program re g the system and facility into full campli- Please, consult the local regional office of the Department quirements of 3�� CMR 5.00 and 6.00. R tment for Further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Crooked Pond Road. Hyannis M a. Owner: D. Neale. Date of Inspection: 07/16/96 Check if the following have been done : -x Pumping information was requested of the owner ,occupant and Board of H ealth. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. -x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the S oil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Crooked Pond Road. Hyannis Ma. i Owner: D. Neale Date of Inspection: 07/16/96 RESIDENTIAL: Design flow: gallons Number of bedrooms : p L Number of current residents: pa. Garbage grinder(yes or no): NO Laundry connected to system(yes or no): Seasonal use(yes or no): No Wa ter meter readings, if available: P,, La st date of occupancy :VWk)t COMMERCIALANDUSTRIAL : Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present(yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no) : Water meter readings, if available : Last date of occupancy: Other: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING REC��ntORDS and so rce of information : � ... . r �N ................. System pumped as part of inspection(yes or no):......../J v...... if yes, volume pomped: .................... gallons Reason for pumping:............................. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Crooked Pond Road. Hyannis, Ma. Owner: D. Neale. Date of inspection: 07/16/96 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system --- S Ingle cesspool --- Overflow cesspool --- Privy --- Shared system (yes or no) (if yes, attach previous inspection records,if any) --- Other (explain)......................................................................................:.... PPR 0 1 MATE AGE of all components, date installed (if known) and source of information . ...... ......................................................... .... ................................................................................................................................................ ............................... Sewage odors detected when arriving at the site : (yes or no).....tAcj. SEPTIC TANK : ... (locate on site plan) ' Depth below grade: ....L... Material of construction: ... . concrete ......... metal ........ FRP ........ other (explain) ................................ ............................. Dimensions: �.� 1-t Sludge depth :...0."...... Distance from top of sludge to bottom of outlet tee or baffle:........3`!................ Scum thickness :...... .".......... Distance from top of scum to top of outlet tee or baffle: ....... I o..�. .............. Distance from bottom of scum to bottom of outlet tee or baffle:.......1.o.)............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level idndfflIrel�ki to pytlet invert, structural integrity evidencef leakage etc.):...�................ PUNA Qt11.. ..... .ju, . .... ..gCj.0 c .. .. . ..... n!. �-it ...5d ..N ......!...4.. �� !!�-�....... .... ........................................ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: 6 Crooked Pond Road. Hyannis, Ma. Owner: D. Neale. Date of inspection: 07116/96 GREASE TRAP: ... RAP: ... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP.........other(explain).... ............................................................................................................................. Dimensions:................................ Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity: evidence of leakage, etc.)........................ . ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:............ (locate on site plan) Depth below grade:.:........... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ E U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Crooked Pond Road. Hyannis M a. Owner: D. Neale Date of inspection: 07/16/96 DISTRIBUTION BOX:...1#5 (locate on site plan) Depth of liquid level above outlet invert:.... Comment: (note if level and distribution egual evidence Qf solids carryover, eviden a of leakage into oriof b t e ). ..'� 1.� 2���tlo?^'.. 4? ►�4.. i.. NS. .c -s�d................. ................................................................................................................................................ PUMP CHAMBER:.... .. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):..l C.:S......... (locate on site plan, if possible, excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ . ................................................................................................................................................ Type: leaching pits, number: ... leaching chambers, number:........ leaching galleries, number:........... leaching trenches, number, length:..................... leaching fields,number,dimensions:................... overflow cesspool, number:.......... Comments: (note ndition of soil , signs of,hydroulic failure, level of ponding,can ikion of vege kion, c.)... .. ?.�... .� L.5'tmo ...N0...S.9.t'�. ... �... ........... ... . . ....... ..... ... r tN..C.�..�.... .... .P...!..?.... .... ...... ...... . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 6 Crooked Pond Road. Hyannis Ma. Owner: D. Neale Date of inspection: 0717 6196 CESSPOOLS:....0.... (locate on site plan) Number and configuration: .................................... Depth-top of liquid to inlet invert: ........................... Depth of solids layer: ............................................... Depth of scum layer: ............................................... Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY : ...0...... RIVY : ...0...... (locate on the site) Material of construction: ................................... Dimensions: ....................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i Property Address : 6 Crooked Pond Road. Hyannis, M a. Owner: D. Neale. Date of inspection: 07/16/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' A. 0 3 O � DEPTH TO GROUNDWATER: Depth to groundwater: 1.1..1....feet Method of determination or approximatirre: � .5.2....1 .1.4....�.�.....Nn....�!!,?... .... ....BeIG.........f 8.....!........................................ ................................................................................................................................................