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HomeMy WebLinkAbout0093 CROOKED POND ROAD - Health 93 Crooked Pond Road 291-313 Hyannis u it e 1 1 a, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F= C9 93 Crooked Pond Road 0 Property Address Michael& Richelle Cabral Owner Owners Name information is X required for every Hyannis MA 02601 8/25/2017 page. City/Town State Zip Code Date of Inspection LO 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 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Forrester L. Quinn use the return key. Name of Inspector F.L. Quinn � Company Name P.O. Box 514 Company Address Orleans MA 02653 City/Town State Zip Code 508-255-4544 S1596 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: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further ion by the Local Approving Authority 7 >7 Y-JY 17 Ins tors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. VS t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 93 Crooked Pond Road Property Address Michael & Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: EI/I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael 8r Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.� 93 Crooked Pond Road Property Address Michael&Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ©/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments „ 93 Crooked Pond Road Property Address Michael&Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ E/ 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. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 2!r Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [E� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ M/ 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.) ❑ 19 The system is a cesspool serving a facility with a design flow of 2000gpd- / 10,000gpd. ❑ / The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM '< 93 Crooked Pond Road Property Address Michael&Richelle Cabral Owner Owner's Name information is Hyannis MA 02601 8/25/2017 required for every y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [� Were any of the system components pumped out in the previous two weeks? (� ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not u 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? Ed ❑ Were all system components,a*cluding 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. d El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 93 Crooked Pond Road Property Address Michael &Richelle Cabral Owner Owner's Name information is Hyannis MA 02601 8/25/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: s doe"" ( I gfy- 1�e�c `✓' n-e — o Xo� � �loro arC�cve(CS W 17�' _S4�jW IMy&JD c?'y` X 1:3` x Q Number of current residents: Does residence have a garbage grinder? ❑ Yes [5"'No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes e No information in this report.) Laundry system inspected? ❑ Yes Ef No Seasonal use? ❑ Yes eNo Water meter readings, if available(last 2 years usage(gpd)): a6/&.- a64(,p1ADA a91r/- i789Pfi Detail: Sump pump? ❑ Yes [i?""No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °.a 93 Crooked Pond Road Property Address Michael& Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information:, Was system pumped as part of the inspection? ❑ Yes Er'O'No 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 ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael&Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 7_140 4c - 101 714 J OS J06-3 Were sewage odors detected when arriving at the site? ❑ Yes [3"'No Building Sewer(locate on site plan): y Depth below grade: feet Material of construction: ❑ cast iron [?(40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): (�if Pi Pir wq /0,1 kJ :AJ C`o� ' 667WDf: C 4041 Septic Tank(locate on site plan): a� Depth below grade: feet Material of construction: [concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1 ooa C 4(& Sludge depth: t5ins.doc•rev-6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael& Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 C How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tic #4 t 4 W -A nl�2�rlv2 (� e "V oal Aw'&'m pro fF�UCi'y���of ,SG7in Me 49-q-1 m e. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93 Crooked Pond Road Property Address Michael& Richelle Cabral Owner Owner's Name information is Hyannis MA 02601 8/25/2017 required for every y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael& Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): �o`ADS c/ ya 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.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael & Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: [r leaching chambers number La) ❑ 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.): po SiC1M er FfN1114V � PaVbJ411Z tA3e i-7-1 SrAl'U 1 rj Flo v� rt Dt-t;rWDi Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth=top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael & Richelle Cabral Owner Owner's Name information is required for every Hyannis MA 02601. 8/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uM y 93 Crooked Pond Road Property Address Michael &Richelle Cabral Owner Owner's Name information is Hyannis MA 02601 8/25/2017 required for every y page. Cityrrown 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 . 03 0 o% � P Q6 A b 1. ID E b Lao �r 00 2, 40 (2, -W,5 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Crooked Pond Road Property Address Michael & Richelle Cabral Owner Owner's Name information is Hyannis MA 02601 8/25/2017 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells C Estimated depth to high ground water: " ' 7 &ow `./�-�7 fG n feet S n 3 /Jo 6®UnIq 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: _ 0-?3 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: W Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93 Crooked Pond Road Property Address Michael& Richelle Cabral Owner Owner's Name information is required for every Hyannis. MA 02601 8/25/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist 5(Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed V ystem Information—Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 117 J - Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 93 Crooked Pond Rd. � \ \ Property Address US Bank National Association TR Owner Owner's Name information is required for H annis Ma. 02601 1/17/2008 y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information . forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name rae P.O.Box 763 Company Address Centerville Ma. 02632 remm City/Town State Zip Code. (508)428-4028 S14454 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. . ` r �' ❑ Needs Further E luati the Local Approving Authority 4 , 1/17/2008 Inspe is SI nat r Date �, n The system inspector shall submit a copy of this inspection report to the Approving uthority(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. 93 Crooked Pond Rd.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C4M ; 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1il7/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section.D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 13) 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. 4 ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due 'to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)'are replaced ❑ obstruction is removed 93 Crooked Pond Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 f, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by-the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool.or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for- Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. 93 Crooked Pond Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is Hyannis Ma. 02601 1/17/2008 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided.that no other failure criteria are triggered.A copy of the analysis .and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.] have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. �E) Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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. 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's'Name information is Hyannis Ma. 02601 1/17/2008 required for y every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health. ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® 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? N. El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the.Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Crooked Pond Rd. Property Address US Bank National Association'TR Owner Owner's Name information is Hyannis Ma. 02601 1/17/2008 required for y every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN.flow based on 310 CMR 15.20.3 (for example: 110 gpd x#of bedrooms): .330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2007: 7,0000 g ( y g (gpd)): 2007:67,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? _ ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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: 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) El maintenance 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: New leaching installed 2003 - Were sewage odors detected when arriving at the site? ❑ Yes ® No _ 93 Crooked Pond Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for. H annis Ma: 02601 1/17/2008 y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building.Sewer(locate on site plan): 1 Depth below grade: feet Material of-construction: ❑ cast iron ® 40 PVC ❑ other(explain): . Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 93 Crooked Pond Rd. Property Address -US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee o�baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has 2 outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 93 Crooked Pond Rd.•11107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 93 Crooked Pond Rd. Property Address US Bank'National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: - i Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching chambers were dry at time of inspection. i 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name information is required for Hyannis Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 J .-Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Ma Abutters Map Size Zoom Out j J�J Ili]� J . In p J JJJJ l X Y { r _ - j - W >�YI •N �f y�y'�'4s^ 4 t r� 7" , 1ryy' i- It 4 � l' tY 20 Feet ` Set Scale 1° = 2b I Aerial Photos (.nn,,ri h+')nnF,_')nm Tn%,,n nf Pornc+ohlo nAA nu rinhtc rmco— htt,D://www.town.barnstab le.ma.us/arcims/appge'o app/map.aspx?propertylD=2913 13&map... 1/17/2008 Commonwealth of Massachusetts .W: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments �M 93 Crooked Pond Rd. Property Address US Bank National Association TR Owner Owner's Name \ information is required for Hyannis. Ma. 02601 1/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of chambers 25' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 2003 If checked, date of design plan reviewed: Date Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board,of Health - explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 93 Crooked Pond Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1HE Town of Barnstable "' OF Tp� Regulatory Services B, WABLE Thomas F. Geiler,Director MAM 1619.. ArEo rur" Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02661 Office: 508-862-4644 Fax: 508-790-6304 This septic s stem inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". -If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. Date: 1111105 I I 1 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: (/jH /77Aa/A&60--)6AT BUSINESS LOCATION: 613 C k OOK_r) Pow y2a( - li gnr7is an Q2 60/ { MAILINGADDRESS: AmC_ Mail To: Board of Health ' TELEPHONE NUMBER: G y 15 3 U(-/ Town of Barnstable CONTACT PERSON. 1)E,Souz e'? P.O: Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: 0 77-V r336 3 a //0 Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO ` This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for yoUr,convenience. If you answered Y,ES�,above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: • TELEPHONE: /1/0 �A�'�1�.'Jc�U.S 127W LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. :. f QuantitY Quantity % it Antifreeze(for gasoline or coolant systems) Drain cleaners ~ANEW USED Cesspool cleaners Automatic transmission fluid Disinfectants 4- - Engine ard=radiator flushes Hydraulic fluid (including brake fluid) Refrigerants !Motor oils Pesticides y NEW ,,g, USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) 'i Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) r lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes I' Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint &varnish removers, deglossers Any other products'with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes: Laundry soil& stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS FAILED INSPEC�'ION DATE ; 3/12/03 PROPERTY ADDRESS 9 3 Crooked Pond Road _ Hyannis---------------- _ Mass_02601 -- �� ` ------------- On the above date, I inspected the septic system at the above address, This system consists of the following: FHEALTH ECEIVED 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3 . 1 -1 000 gallon precast leaching pit. R 1 7 0003 Based on my inspection, I certify the following conditions: OFBARNSTABLE 4. This is a title five septic system. ( 78 Code ) CJEPT. 5. The septic system is in hydraulic failure. 6. A new leaching area needs to be installed. 7 . Waste water & septage is above all of the invettsand outlets of the system. 8. The system needs to be pumped. SIGNATUR Name : _ J .- P . _Macomber Jr , C0mpany :2gatpt P_,_M�r4ml�€r 8_ Son, Inc . Address :__@Qx ............ __C�_rURZYiUP,_Na-_Q.Z632-0066 Pnone :-_508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY IOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville, MA 02632.0066 775.3338 .775.6412 COMMONWEALTH OF M,ASSACHUSETTS r 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: 93 Crooked Pond Road Hyannis,Mass. Owner's Name:Herbert Cole Owner's Address: Same Date of Inspection: 3 12 0 3 Name of Inspector: (please print)_Joseph P.Macomber Jr. Company Name: J.P-Macomber & Son Inc. Mailing Address:gQx 66 rgnnt•erv> 11eyMaRR 02632 Telephone Number: STIR-77S-3338 CERTIFICATION STATEMENT 1 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 traiping 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: i Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature• � Date: The system inspector sha�mit 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 4conditions of use. r Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 93 Crooked Pond Road Hvannis,Mass . Owner: Herbert Co-Le Date of inspection: 3 12 0 3 Inspection Summary: Check A,B,C,D or E/AI,WAyS complete all of Section D A. System Passes:�� `� hav not found any iD_f_or�mat',on which indicates that any of the fail riteria described S 303 or in 310 CVR- 13.30 ex�Any failur— e-`criteria not evaluated aree indiica ed below. in 310 CMR Comments: system is' in lZydraulic failure. A new leaching are nQ-dq to he installed. 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. '046 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 cxfiltration or tank failure is imminent. System will pass inspection if the existiAg 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 ate of Compliance and if a Certific indicating that the tank is less than 20 years old is available. ND explain: yP, servation of sewan• �r break out or high static water level in the distribution box due to broken or obstructed Pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: Ird The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 ,r OFFICIA_l. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:93 Crooked Pond Road HYni,Ma s s_ OwoerHerbert Cole Date of ►ospectioo: 3 1 2 03 C. Further Evaluatioo is Required by the Board of Health: V Conditions exist which rcqu' c funher evaluation by the Board orHealth In order to determine if the system is (ailusg to protect public health, safcty or.the environment. I. S.stem will pass unless Board or Health determines In accordance with 310 CMR I5.303(1)(b) that the system is not fuoctioning in a maooer wbich will protect public bealtb,safety and the enviro_oment: 420 Cesspool or privy is within 50 feet ofa surface water Cesspool or privy is witbin 50 feet ofa bordering vegetated wetland or a salt marsh 2. S.N stem will fail unless the Board or Health (and Public Water Supplier, irony)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. tV The system has a septic tank and SAS and the SAS is within a Zone I ofa public water supply The system has a septic tank and SAS and the SAS is within SO feet ofa private water supply well. d)d The system has a septic tan); and SAS and the SAS is less than 100 feet but S feet or more from a pri aie eater suppl. tell" Method used to determine distance 'This s.\stem passes if the well water analysis, performed at a DEP eenifted laboratory, for eoliform bacteria and volatile organic compounds indicates that the well is bee from pollution from that faciiiry and the presence or ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are rriggered. A copy or the analysis must be anaehed to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 93 Crooked Pond Road Hyannis,Mass _ Owner: Herbert Cole Date of Inspection: 3/1 2/03 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 ti�i�—ldav _✓ Liquid depth in�M is less than 6"below invert or available volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped /arty 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. /`rty 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.) 74' (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 be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply i' the system is within 200 feet of a tributary to a surface drinking water supply t e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed corder Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 93 Crooked Pond Road yannis, ass. Owner: Herbert Cole Date of Inspection: 31r0 3 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No / Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection ? ./ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? ✓ _ Were all system components,�onluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bafflesor tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? _4 _ 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 93 Crooked Pond Road Hyannis,Mass . Owner: Herbert Cole Date of Inspection: 3/1 2/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �rila �4V Number of current residents:_ Does residence have a garbage grinder(yes or no):yE S Is laundry on a separate sewage system.(yes or no):­Ue7(if yes separate inspection required] Laundry system inspected(yes or no): , Seasonal use: (yes or no): yv Water meter readings, if available(last 2 years usage(gpd))2 0 01 —5 7, 500 gallons=1 57. 54 GPD Sump pump(yes orno): �2) 2002-55, 000 gallons=150. 69 GPD Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): z/V gpd Basis of design flow(seats/persons/sgft,etc.): ,,i9 Grease trap present(yes or no): Industrial waste holding tank present(yes or no):,L, 9 Non-sanitary waste discharged to the Title 5 system (yes or no):,,&,# Water meter readings, if available: Last date of occupancy/use: _ AL14 OTHER(describe): ,yr¢ GENERAL INFORMATION Pumping Records Source of information:4/25/98 & 9/1 9/01 Tank only Was system pumped as part of the inspection(yes or no):," If yes, volume pumped: e3 gallons-- How was quantity pumped determined? Reason for pumping: �)A TYPE OF SYSTEM k/Septic tank,distribution box,soil absorption system 4,Y Single cesspool ,t,P Overflow cesspool Ic' Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) /W Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ,�Tight tank 0 Attach a copy of the DEP approval Other(describe): IV A oximate age of all components, date installed (if known)and source of information: p : �y Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 Crooked Pond Road H_vanni s .Mass Owner: Herbert ('ol in Date of Inspection:'i 1 210 3 BUILDING SEWER(locate on site plan) Depth below grade: Q ,l / Materials of construction: _cast iron ✓40 PVC A/e other(explain): ,t/A Distance from private water supply well or suction line: ld`f Comments(on condition of joints, venting,evidence of leakage,etc.): Joints appear tight No evil n P of leakage ThP qyctem , s vented through the house vents./ SEPTIC TANK: d (locate on site plan) /41l? Depth below grade: Material of construction: 'concrete metal Pjfiberglass4 polyethylene ,, other(explain) ,U/1 If tank is metal list age: 4Po Is age confirmed by a Certificate of Compliance(yes or no):�(attach a copy of certificate) Dimensions: '.'�,�+.tYa Sludge depttr����L Distance from top of sludge to bottom of outlet tee or baffle: Ze,� 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: How were dimensions determined: �� Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Pump septic tank ann uaI 1 C'arhage riis?osaI i c present -Inlet & Outlet tPPs are i-n place The tank is strum -ai`i —send and shows noevidence of leakage-Waste & waste water is in the C:RE1W TKAy Ve (locate on site plan) Depth below grade:WO Material of construction:/0 concrete,�ilmeta(,iZ,�_fiberglass4A polyethylene/,) other (explain): 1410 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ' 99 Distance from bottom of scum to bottom of outlet tee or baffle:_4'J'4 Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease trap is not present- 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 Crooked Pond Road Hvannis Owner:Herbert ole Date of Inspection:3/1 2/0 3 TIGHT or HOLDING TANK4,�4Lt,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 4)14_ Material of construct��: !,JQ concrete egmetal?/�fiberglass,12,4, polyethylenetiY other(explain): Dimensions: ti/0 Capacity: gallons Design Flow: ltx gallons/day Alarm present(yes or no):_Xl Alarm level: M Alarm in working order(yes or no): 414 Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present DISTRIBUTION BOX:Zif present must be opened)(locate on site plan) Depth of liquid.level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Di_s_tri htfi-i nn hnx has nnA 1 atera.l `-ahQr-o is AyidenGe-ef- 6eliEl5 ,-j G ver,N Q e v i de ne-e—e= l ea l age—mot e— „—e tt b--e re—fie . PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 211mi chamber- i s not n-ensg�t- i 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 Crooked Pond Road Hyannis ,Mass. Owner:Herbert of Date of Inspection:-1/1 2/()3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1 -1000 aallon Dr _cast leaching pit Pit is in failure A new leaching area needs to be installed. If SAS not located explain why: T—cated• cAA pane 1 n Ty l/e _ leaching pits, number: leaching chambers,number: O leaching galleries,number:Q leaching trenches,number, length:sj 2 leaching fields,number, dimensions: 0 t1d overflow cesspool,number:0 � r _;�T innovative/alternative system Type/name of technology: /ll'1e d1� f� Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to boney medium sand to fine sand.The leaching pit _ is in r ulic fail_ure.Waste water is above Inver pipe. new leaching area needs to be installed.Soils are damp. Vege a ion •i s normal ' CESSPOOL; UYt (cesspool must be pumped as part of inspection)(locate on site plan) Number.and configuration:_ Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: E4 Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Cesspools are not present PRIVY,�L(locate on site plan) Materials of construction: Dimensions: ,Q Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. 9 �r ` Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 Crooked Pond Road Hvannis.Mass . Owner:Her of Date of inspection: 3 1 2/o 3 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. Cxb o t'p r1 C� rJ I .i 10-) \� % 10 r Page 11 of 1 I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 Crooked Pond Road Hyannis,Mass- Owner: Herbert Cole Date of Inspection: 3/1 2/6 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: #61 Ob s stem deli plans on record- If checked,date of design plan reviewed:Observed site abuttin ro a observation hole within 150 feet of SAS) 4)b Checked with local Board of Health-explain: AW Checked with local excavators, installers-(attach documentation) y�Accessed USGS database-explain:f j ,pr l/,yyd� tf yiyyyi9(,��, A = ' You must describe how you established the high ground water elevation: Used: Gahrety & Miller Model 12/16/94 Ground water elevation above sea level. Used: UBGS:Observation well data June 1992 Used: USC;S-TPnhni cal bL1 1 Pt i n 92 000 1 l a P #2 Annul ranges of ground w r'?t"4P r P l P V t a l Rffl - - - run Leaching f Pit :eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is � feet. 11 o >•nrnr+r.-nrr�r--+r trnrmr•ass+rrr�.'rainrrm::�e-rt+�.n+sr*m.*n m�+t7.r isw-�asar.ia�+ .. �1 TOWN OF Barnstable BOARD OF HEALTH SUDSUIZFACF SEWAGE; DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .•••rrt�r••r::t-r...��.-rnmrtnn.�rw•sae+rrn-nrr.'-.t�*�ve+er�snnn"�'�w�ww�newmrt�n�s tsm r.+trr+-•r-„ -..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 93 Crooked Pond Road Hvannis,Mass ASSESSORS MAP, BLOCK AND PARCEL # 291 -313 OWNER' s NAME Herbert, Cole PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J-P.Macomber & Sony Ino,-e COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or CSty Stat• L!P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 1 790 - 1 578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dispose`], system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; Systeui PASSED j The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. v System FAILED* , The inspection whicl, I have con Meted has found that the system fails to protect the ptiblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ✓�/ Date and. copy of this d rtification must be provided to the OWNER, the BUYER here applicable ) and the. BOARD OF HEALTH. * If the inspection FAILED, the owner or""operator shall upgrade ayste within one year of the date of the inspection, unless allowedorthe requiredm otherwise as provided in 3.10 Ch1R 16 , 306 , partd .do' TOWN OF BARNSTABLE SEWAGE # ate •, r��Z LOCATION , VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII;ITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: Ste`° -� COMPLIANCE DATE: Z� 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist ✓ Feet within 300 feet of leaching facility) Furnished by 6 � i_ +� ,( i cam TOWN OF BARNSTABLE LOCATION ` �t C"d '� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /moo G X%Jim LEACHING FACILITY: (type) NO. OF BEDROOMS— BUILDER OR OWNER _ PERMIT DATE: �" �"�� COMPLIANCE DATE: �Z'z U 3 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 ✓ Feet within 300 feet of leaching facility) ti� Furnished by - r u 0 qL v ---------- 0 LOCAT ON SEWAGE PER IT 0. G PD \l® LIZ VILLAGE L49/,36 INSTALL/ER'S NAME i ADDRESS , BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED V� Vz� w F ..` Z No. 2D 3- ) ! Z t Fee THE COMMONWEALTH OF MASSACHUSETTS/ Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for ]Diopozal *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair( . )Upgrade(Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ;,)9/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ®7 �i�lesb /je(.Pp ti �t•1'. FJJ 2,/.7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building of'C.t'. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�o gallons per day. Calculated daily flow -�G' gallons. Plan Date .7-z), Number of sheets Revision Date Title Size of Septic Tank <—X4P7T 1 3 ��e►o<`, Type of S.A.S.a Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this Board of Health. 0 Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. ZQ 3- I r7 Z Date Issued ' No. w -« • M Fee -a. 4 _y j Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS t 21pphrattou for Migpogal *pgtem Cougtruchou Perron k Application for a Permit to Construct( )Repair( )Upgrade(�Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��,� � 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 Ste— .7 : Number of sheets .00 Revision Date Title Size of Septic Tank 9X Z' Type of S.A.S. rho �/yk l,&e r Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu y this Board of Health. 0 - Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 20 0 3- I r/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 ( )Upgraded,) Abandoned( )by l /" Z at "Oek. has been construc ed in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZU U 3—/7 2 dated L 2 3 C)3 Installer Si L. 2 K Designer q s� The issuance of this pe t s all not be construed as a guarantee that the systeMln�o a esigned. Date 2 S D Inspector No. Zoo 3 f 117 Z Fee fps/ e'J'Aeew tKv S+ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=isSpogar 6petem Cou5tructton Permit W k S d) sion's' ereb ranted to Construct Repair Upgrade Abandon System located at 9 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 perrrtit' Date:_ c� �3��3 Approved by 71) ION SEWAGE T IVEOr, A i��'ylyl� i IN.STA LLER'S NAME & ADDRESS B UI'LDE R OR OWNER DATE PERMIT ISSUED, DAT E C.0-MPLIANCE ISSUED 1 -,�. �'� W A4 � �- � �� ! � � -� ;r � � �� i �1 � i { I E �� �� '1 d ! � � I �, 1;: No. 9 * Fss.......0 5............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH _ �, 3 . ....... ....O F....... .. ... ... .... .. . ..... .....:..........------...........-------- Appliration -for Bi.ipoittl Workii Totw4rortion Prrotit plication is hereb made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: / ------------------------- - Location• dress or Lot N : a - -- - ----------------------..... a � - p� Own r l dress Installer Address CG Type of Building Size Lot....l_o.fM .__......Sq. feet ., Dwelling—No. of Bedrooms---------------S5------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persolis--------(e---------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... ... W Design Flow...........�f ....................gallons per person per�ay. Total dail flow........ .................gallons. WSeptic Tank—Liquid capacity_f.Q Q_ allons Length._._........ �Vidfh.._ .__._.. lliameter________________ Depth....______...... x Disposal Trench—No. .................... Width.....- ----_--_---- Total Length------------- ._.. Total leaching area....................sq. ft. Seepage Pit No------------/------- Diameter..__:'__�_r-.-- Depth below inlet----AA.......... Total leaching area.--41-3-___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by:__ a.x.Q.S ••h'.... ____ Date._ .Q../ .... Test Pit No. I....:...........minutes per inch Depth of "Pest Pit.................... Depth to ground water_... _. .___ .. _ _ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_1_�___4�___�r " / Pi `� 3------------------- - I. O Description of Soil------------------------------ - -'---�-°1_------- _-,e [ arc - -; ------------------------- x ~.------�-1.. ------------------------------------------------------------------------------------------ W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by e oard o ealth. igned = Q-------------- ------------Da----------------- _ Date Application Approved BY -- ---- ----------- - ----1V.".4_.V-.2_ _ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------........................ -------------------------------------------------------------------------------- ------------------ Date PermitNo......................................................... Issued._Ll-_ -�"' .---.-- Date 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH y; Application -for lhtipoottl Workg Tonotrnrtion Prrutit Application is hereby made for a Permit to Construct ( `) or Repair ( ) an Individual Sewage Disposal System at: , Location- dress Lot Nt 1 j Owner 11 Address f/ ! a Installer Address UType of Building `' " Size Lot...,l.�a..Or.7------Sq. feet Dwelling—No. of Bedrooms_............%3.........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building -----. No. of ersons-------! Showers ( ) — Cafeteria ( ) a yp xt............................----------• -- - ---•-- ---.....-...---- -----------------.............--------------•-------•--•.................... Other fixtures --•------------------•----..... . . . . . w Design Flow---------- � gallons per person per clay. Total daily, flow------- U------------------- Septic Tank—Liquid capacity°. t1 lgallons Length..... s"........ Width.. __ Diameter................ Depth.._..---_---._. xDisposal Trench—No- -------------------- Width.....?---------_---- Total Length------------- Total leaching area--------------------sq. ft. Seepage Pit No..---------/-------- Diameter.........'...... Depth below inlet...X.<a_ ........ Total leaching area_,R_-2..-A.-_-.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) / '-' Percolation Test Results Performed by---- � 1' 'Yt irt_.._ __Y..f. ; ..%r^��:�-r..... Date.- � %--....-_.. a Test Pit No. 1.................minutes per inch Depth of "Pest Pit.................... Depth to ground water._----f.............. . rLI Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water) �._ +�? -------I--------- x --• -K Ix of Soil............................. 4Q--~ 1 -- --------------------------------- - ----- ...... w VNature of Repairs or Alterations—Answer when'applicable.......................:.......L......--.........._..............__.........._---. ----..-._... -----------------------•---..-...------------------•--------•----------••--------------•----.-.-...---•--.....-...:_...----...--- -•----------------------------------•-----•--- ------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has } n issued by th oard health..• Date Application Approved B --- ---------- ......... .............. PP PP Y Date Application Disapproved for the following reasons------------------------------------------------- ---------------------------------------------------------------------------- ------------------------------------------------------------------------ Date PermitNo......................................................... Issued........... -------------------------------------•--•--- ' Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ .......OF......., t4 !y . . -............... AT Tutifirate of 101,11ntlrliFtnrr TH .S IS TO CE _TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....... -.0... 1 -....-- ( Y----••••• --------•••-. f� Insta ler � � at =n .. .Id C?.�`�, _ a , f -�--------------------------------------------------------------------------- has been installed in accordance with the provisions of *t' 1 I The State Sanitary Code as described in the ° . application for Disposal Works Construction Permit N _. -II.:. ................ dated/ a---�_----:"..� ....._.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEInspector ................................................. THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HE LTH ..0..1.f,�..�.. ..OF...��..I� �e�/Z:� . . ........................ �t,. No.••••-•r✓ lam. FEE.-- --••.....:........ 21,,t- Perm> sion is hereby granted f ---r �-�1 �----- '------ ---------------------------------------------------------- to Construct;(*J) or Re air ( ) an Individual Sewage Disposal System ,� 1 I at No.---------- ^` �a�; yj --------------------------------------------------------- r : -------- --•Y•- � / t - Strfet �`����� as shown on the application for Disposal Works Construction "it No >..... ..Ao,,��d�4of Dated_..._. _ 77 Health DATE....... ----------------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Y F��L�v• ��:.i ' ��ti�sH ,�,�AnF•/7X5 }-- ���v�sH G�.�vE ,~�N,.cN G+�,on� OvER -rA *VK OVER /piT s 1b.XS TaP EL E✓ r _(BX.� _ sro it n 6r•IAt.. G == CELLAR F"a.• � /S7f i � �- - - . _ _ ( d i1, � � _ j I s /Goo 6AL• j I I/ �� 4' fLf✓ �� 1L-X2.� I D 1.5 -r o CS O X , �I (r.¢uy,yea .S'�o.✓E A/`i D Sr�QL.E O c ` c .AOTTb N O f o f LE/9CN/NG P/T 47.S7 GAL. �E�e DyY 330 R•38. GA <`A NIMF r,'t A cf/•N GR/N�E�t' /vG.NE T=3a.ao L EAG N/N G i4i2EA ,PEQ 7�. : O/�i � ��;'o r � ` s�-•o � L EAGw/i✓6 i4,P6�9 CPC v/QED : .co�3S � - .S/DEtc�ALL 4d? O o P} v 'ro. gkfA = Sc Tor.4C. = 4 S7 6,41- S. /45JLaF /oa a 7-d 'To ! -�oT38 1ar37 Cou�S'E' j J;441=) t t i { 4 I - 4XO --� P f/P PoSe_D SE w.4CW 1SPOSA4 1'Sr.F/rJ rfn .a /�i6aA OSED L/NG DArf ac r 4 R77 e�,v.ra,✓ sa . ,V6,4[Ti4/ /yi4N,N/S Cf3,4,eAlST SZ,,l_ )4 /"7A5s- ��Toc• a.4TE 2.y,�v��, sc its i ••-3a' X"F'd oC r-/.r 977 ---��, OwN�E•! : cE�,oe .gc,PES ,PE,4LTf/ 7pus7' Of /►7i93S- NOWAN ence} GRASS C MAN su-. 1 CEWrArRV/LLB /1-9i4SS• F�6Ll�'• LLB- , � �INiSH v'PADf-• XS r- � , O vCR Tip n/K = 12—yo ovEa PST s Top aFro�Nta. ���`iiivr►..,�ff�`xr.`yw,'J//�.i/art/ �w6LL !/V C.- ",,WAis - 3 -��.�9 J I CELLA R `L j IiA jr be x ;� -- --t i t IPEr N ft�KED GGNG D 15 T 13 O X / / `oj A j . ' I ` j- C t+u9 yfa S�ra.vE • L O U �. J - 10 / - S I SEP -1 C TANK _ -^r D s'rEoaE.E t\\N / aA I A9107TL3N O f 1/r ELE1w = Bxd 7-6 5-C.Az4f LEI➢CN/NG J'pir DES/_Gw cep rE� �60 aell'Nvfk Sy= 'e /VO- OF AMEDeOOMS GAL• PEA 7711y ' �,30 R•3p. 6",e L;�E 6R11VT�d R NONE T =3a-do TorA� r�.4iLy FLoi✓: 330 _��- J--�► ` Or.r 1 �,o v S/DEcuALL A.QfA z /63�'xZ_5= 4G7 E � a , VIC 71 .pitf Q 4 S7 GAL O/G L 04-0 r /SYS LoTNO. 36 }� - 1 Tb � .GoT-38 1aT37 Gou�<S'E f Jf�N� I I I ; �,ovEL , P,PoPoSEDSeW,46C AO/SROSA4 So -F? E1 9 /.✓sPr�rfD AX c,� ,•�a,e,rt,ay f'���4SG�D 1�/YEL L/NG D�+r` ac-r 4� R77 $,o.r/,✓ sD. A145WLTiS/ ,yy,4�(' 1//4 CI3A�iVSTAIIL � /�'1/4 ss• ��x• ,BATE= �v�,y oc r-/.r 197' �M OF ow/KE8 : cEDAe .gc,PES iPE.4LTy 7�.ES'r / '\�N Of 1� ~ Nord" iA A DMAN ? t GWAS NOrP/`!AN 6 i.S.SY`'�N 1rE• CEAe7-ArR v111L.E. MASS' crpoyra Polaq r a co �,au nary � 6�� sTA 7RS a3 Gvov-ccl paid P4 . AJ o-n ra S MA oa�l LtJ1Y\0� �L � Q� �ckr00m �L. oo t CA^\ ib J `f 2g ASSESSORS MAP : 1A I - � --- TEST HOLE LOGS PARCEL: �J� _._ _._._.- I NOTES: FLOOD ZONE: "(5,1 SOIL EVALUATOR ._ V ----- �'�------______._-------- q SM�fi4N WITNESS: . dT � --------- - S REFERENCE �[�, � DATE: Iq l- 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLATION RATE: .4 ml _ Health Regulations. 2 The installer shall verify the location of utilities sewer inverts an) fy d septic TH- 1 TH-2 components prior to installation. �4 3) All septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 4) Existing leach pit to be pumped and backfilled per Title V abandonment ��� � /✓' /'"'M - 5) This plan s not to be utilized for roe line determination nor an other -- property rtY Y purpose other than the proposed system installation. LOCATION MAP C�T�� 3 �� # 1 6) All septic components must meet Title V specifications. ,!�,.f _qt -_____- _ 7) Parking shall not be constructed over H10 septic components. k' f 8) The property is bounded by property corners and property lines as depicted. .: , / ✓�'`I� 9) The property owner shall review design considerations to approve of total number (,,• of bedrooms to be considered for design. Apr � 10) The installer is to verify that the tank is a 1000 gallon minimum tank. If such is less than 1000 gallons then it is to be replaced with a 1500 gallon tank. sr � 1 h SEPTIC -SYSTEM DESIGN FLOW ESTIMATE 3 BEDROOMS AT 110 GAL/DAY/BEDROOM - GAL/DAY (EVMTAKI (io—- - ,�-- �l v GAS./DAY x 2 DAYS - GAL 3 USE 1COD GALLON SEPTIC TANK_ X1 l SOIL ABSORPTION SYSTEM YCI --q S 1 DE AREA: Z �t `. / : . BOTTOM AREA: Z: X 13 t7�7 - 230� ✓�J ZHO 0 SEPTIC SYSTEM SECTION ZIC o 1000 GAL SEPT I C TANK 3j1P 66 SITE AND SEWAGE PLAN w LOCATION : q� G(1.C7�C UD TDVI[ ) RDAP \ V " Y^� PREPARED FOR : P M O SCALE a W DAV I D g . MASON V) DATE: L, U Z DBC ENVIRONMEN AL DESIGNS EAST SANDWICH . MA 3 DATE HEALTH AGENT ( 508 ) 833- 2 177 W Z