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HomeMy WebLinkAbout0030 DUNN'S POND ROAD - Health 30 Dunn"s Pond Road Hyannis P A = 270 021002 i r t is 4 TOWN OF BARNSTABLE LOCATION 30 ZunnS Pan,( RJ, SEWAGE# Zo19- (4zt4 VILLAGE ASSESSOR'S MAP&`PARCEL 270-01— INSTALLER'S NAME&PHONE NO. xcaV«Aior\ 'Ang 0l.53 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY.(type) S=OOQ,�,J L4c (size) 03 x 2 S x Z. NO.OF BEDROOMS OWNER U PERMIT DATE: $ 9• I y- t 9 COMPLIANCE DATE: -7/J9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching cility)A = s _ „ Feet FURNISHED BY �i r W C c S 5 . a 1 A O O a ' TOWN OF BARN STABLE SO � RC� SEWAGE # un�s Pow VILLAGE uy/ )J ASSESSOR'S MAP fit. LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IOUI) LEACHING FACILITY: (type) (size) 0lK NO. OF BEDROOMS l BUILDER OR OWNER � � ✓61tw1jAk PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300'feet of leaching facihw. Feet Furnished by FO/e L W �� �_ v �� � � � t� W 0 � W , � , J 4 ' � - � � � .. - � TOWN OF BARNSTABLE, �LOCATIN d V SEWAGE # `q,LAGE 3 ASSESSOR'S MAP & L0]� INSTALLER'S NAME&PH NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility, (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by kav 9. T � o eo oa , iI O r� a �� TOWN OF BARNSTABLE LOCATION ` f _ SEWAGE # VILLAGE ASSESSOR'S MAP & LOTS , INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY DQ® Q I LEACHING FACILITY:(type) (size) NO..OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 1' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No % �I I r ' r Al. TOWN .BOFBA�RN-�STABLE LOCATIOCDD )01S 1'! d IC.-�., d SEWAGE # VILLAGE JA 01 n 1110 ASSESSOR'S MAP & LOT Z2OOZ1-M7 INSTALLER'S AME&PHONE NO. SEPTIC TANK CAPACITY ii flfl t ti LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER NYt Q, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet Furnished by P a t y No. e� Fee (Q Q -- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftprication for Disposal 6pstem Construction Permit Application.for a Permit to Construct( ) Repair-( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. . An'S pond (i; ma Owner's Name,Address,and Tel.No. Q t nc jow-V tot r o... Assessor's Map/Parcel 27 r, nni�) Installer's Name,Address,and Tel.No. �3`6 � .(y v a}2 _. , Designers Name,Address,and Tel.'No.-1/14•A q4• I I(o to �+ 3'74 fcu� hey Cruiro n+p.\ P.o0eox Type of Building: Dwelling No.of Bedrooms Lot Size _I ,,quo sq.fl-10-�Garbage Grinder(No) Other. Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ' 2 0 gpd Design flow provided 349 gpd Plan Date I �tifl9 Number of sheets Z, Revision Date Title 'S6:�8; aro� Sir.te,ehti patao- Size of Septic Tank 1066'''0 46kur;$ Y Type of S.A.S. Description of Soil ' X Nature of Repairs or Alterations(Answer when applicable)A,CkA- rlica fS;iY an® d 6 $a. s�.�.#� I006 r q Q o.lt o Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed' Date 111131 ICI Application Approved by Date l Application Disapproved by Date for the following reasons Permit No P 14 Date Issued --- __-_-_ - Ov ;; rar=� No. fl L� w, _ Fee ' 00 i- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for 3DIBtlosal *pstrm Construction Permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.30,D«n,%'s Q u ro Rot, i Owner's Name,Address,and Tel.No. Ve�cc.- f-�yf�nn,S Assessor's.Map/ParceI L-1c) ,_ '30 QunnS hU�d ri. �t nn, Installer's Name,Address,and Tel.No. ��4 c c j c,k v n Designer's Name,Address,and Tel.No. t (�°��c ah E`� C ^u c me ant Ro. r5^+ Z �3f� �c:,;ctw,c4. /v1 r' ° '� �3l Nn.c("c�j Type of Building: Dwelling No.of Bedrooms Lot Size �. q l t sq.0 Garbage Grinder(N o) Other Type of Building ` " No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow(min.required) 2 Z h gpd Design flow provided N gpd Plan Date ( i Z��q Number of sheets Revision Date Title S,.4 Size of Septic Tank 10010Type of S.A.S.( 3 n u E_ ��,, I €� �;, , Description of Soil }G•dp Nature of Repairs or Alterations(Answer when applicable) q a,a Date last inspected; t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 11111111 Application Approved by L 5, Date Im.I v Application Disapproved by Date -.for the following reasons ,J Permit No. "� /��Gy -- t Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance e THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandi'ned( )by at N ry has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.1,,r a _t_.0Fr dated Installer R?3 �r .,_1, Designer T!,. ,L`., c #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wilDncos desi ed. Date —7 1 Inspector. No. Fee" rpA �13T THE COMMONWEALTH OF MASSACHUSETTS o�d�/ % BLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at j�,,,� s ��,, , Q a n,, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date i IL. Approved by Town of Barnstable Inspectional Services "='` Public Health Division 06?& , Thomas McKean, Director 9. 200 Main Street,Hyannis,MA 02601 ' Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: J l- 211. 19 Sewage Permit# 7olg = y 314 Assessor's Map\Parcel Designer: IlQ�...r-!�f.�t,�ornncn�o► 0 Installer: -RrrB ExmygAior, Address: P t3 Orac 331 Address: p4-Tcr..Scr rLa is On 1 l- l'-1- 14 r3 4v 3 E xco► o A 1 o ,n was issued a permit to install a (date) (installer) septic system at �o Zunr\S. Port RmL based on a design drawn by (address) dated t0- IZ- 19 (designer) �( I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e.. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. fiAA I certify that the system referenced above was constructed i edie with the terms of the RA approval letters(if applicable) Ssy DAVID ,- D. � FLAHERTY,JR. (I ta11 's Si natdw4 No. 1211 FC,STER� SqN!TA R\P' esigner's Signatur (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoMdeptAHEALTIASEWER connectlSEPTIODesigner Certification Form Rev&14-13.DOC Town of Barnstable , Inspectional Services Department BA S& 1639. � Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKcan,CHO. CERTIFIED MAIL#7015 1730 0001 4988 0909 September 30, 2019 BRUSTAS, KAITLYN J 30 DUNNS POND ROAD HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 30 Dunns Ponds Road, Hyannis, MA was inspected on 09/06/2019 by Patrick T. Sullivan, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic systern within the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH �ean. .S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Rcport Letters Mailing\Failed or Needs Further Evaluation Letters\30 Dunns Pond Road Hyannis.doc �P��ZHE 1pw�� Town of Barnstable • • BARNSCABLE, 039. a Inspectional Services Department AT fD N4A'� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe,relocation of a driveway due to H-10 components, etc) aching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc c Commonwealth of Massachusetts COP' i_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 30 Dunns Pond Road Property Address , Gary Brustas ' Owner Owner's Na my information is H annis V MA 02601 required for every - Y September 6, 2019 - page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information ^'`.� !�1�L.tJ on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 r� Company Address Forestdale MA 02644 City/Town State Zip Code 508-509-0802 SI 12843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails September 16, 2019 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Dunns Pond Road u� Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y _ _p page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. c 1) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15;3 4 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" , N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years Id*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspgction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is less than 20 years old is available. Y N /ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y p page. City/Town State Zip Code Date.of Inspection C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or reak out or high static water level in the distribution box due to broken or obstructed pipe(s)or ue to a broken, settled or uneven distribution box. System will pass inspection if(with approval f Board of Health): ❑ broken pipe(s) are re aced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remo ed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box i leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further.Evaluation is Required by the Board of Health: ElConditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect blic health, safety or the environment. a. System will pass unless/Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the envir7ient: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r - c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6 2019 required for every y P page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption ystem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a rface water supply. ❑ The system has a septic tank and SA/and SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAe SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAe 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 a alysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 30 Dunns Pond Road V` Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6 2019 required for every y p page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the sys/en0 feet of a surface drinking water supply ❑ ❑ the sys0 feet of a tributary to a surface drinking water supply ❑ ❑ the sysn a nitrogen sensitive area (Interim Wellhead Protection Area— pped Zone I1 of a public water supply well t5insp.doc•rev.7/26/2018 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Dunns Pond Road V Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y P page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y P page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220+ GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017= 149 GPD g ( y g (gp )) 2018= 164 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 1, 2019Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 l c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Dunns Pond Road —u— Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 required for every Y September 6, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank prese ? ❑ Yes ❑ No Non-sanitary waste discharged t the Title 5 system? ❑ Yes ❑ No Water meter readings, if avail le: Last date of occupancy/use. Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter records: Pumped 3 weeks ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts r1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............e, 30 Dunns Pond Road V Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6 2019 required for every y p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and,source of information: System installed approx 1993. Previous Title 5 Inspection. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 30 Dunns Pond Road v— Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every Y p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 20"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: 8.5'x 4.5'x 5' 1000 gallons Sludge depth: <1" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Recommend maintenance pumping every two years. M t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I r , c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments In v 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y p page. Citylrown State Zip Code Date of Inspeption D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /EE11 iberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum t/tobfottom utlet tee or baffle Distance from bottom of sc of outlet tee or baffle Date of last pumping: Date Comments (on pumpi recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f 1 Commonwealth of Massachusetts i Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 30 Dunns Pond Road u Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6 2019 required for every y P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alar and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distri ution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, tc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form A� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every Y P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pum/amber, ondition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6' x 6'w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Dunns Pond Road v- Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every y p page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 10" below invert at time of inspection. Black staining 2" over inlet line shows system has been in hydraulic failure. Stone in all visible holes is black. Leach pit is H-20. 1.5' below grade. 12. 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 oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5i6sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6 2019 required for every y P , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs/ofydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,( ry 30 Dunns Pond Road Property Address Gary Brustas Owner Owner's Name information is required for every Hyannis MA 02601 September 6, 2019 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 1 y I 1 j I t 1 c "J i 0 10 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I s , Commonwealth of Massachusetts r _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Dunns Pond Road V� Property Address Gary Brustas Owner Owner's Name information is Hyannis MA 02601 September 6, 2019 required for every Y p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Accessed local ground water contours and topo mapping. Ground water>15' in area of system. Base of leach pit 8' below grade. No high ground water in area of s stem. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c / 30 Dunns Pond Road u- Property Address Gary Brustas Owner Owner's Name information is P required for every y H annis MA 02601 September 6, 2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification:Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 V Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the c computer,use 30 Dunn's Pond Road Grp\S only the tab key Property Address to move your Today Real Estate 09A- 00 a cursor-do not Owner's Name use the return key. 1533 Falmouth Road Owner's Address VQ MA 02632 CftyfTowrr State Zip Code Ili Date of Inspection: 01/05/08 Date 2. Inspector: MR. ROBERT A. DRAKE Name of Inspector • KCJ ENGINEERING ° Company Name -� Q M 66 GREENVILLE DRIVE Company Address - T FORESTDALE MA 02644 City/Town State Zip Code 508-477-5048 %.0 f Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes = ROBERT A. yG ❑ eds Furth Epluation by Local Approving Authori g DRAKE m ju_.f A .1\,J � clvlL No.41642 Inspector's Signature Date The system inspector shall submit a copy of this inspection repo FF � ' LNG g Authority(Board of Health or DEP)within 30 days of completing this inspection. If the s t 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. 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 City/Town State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Septic Tank appears to be structurally sound and working properly, tees are inplace, no ponding around the leaching field. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 7M A. Certification (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3of16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 41M A. Certification (cunt.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State ZipCode Today Real Estate 01/05/08 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 30 Dunn's Pond Road-T51NSP1,DOC,doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5of16 L -- I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y•y`• A. Certification (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection 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. 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments -- Subsurface Sewage Disposal System Form B. Checklist 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® a 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)] 30 Dunn's Pond Road-T51NSPl.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments -- Subsurface Sewage Disposal System Form C. System Information 30 Dunn's Pond Road Property Address Hyannis MA 02601 City/Town State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 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 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: A couple of months ago Commercial/Industrial Flow Conditions: Type of Establishment: N/A 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): 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Citylrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A 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 Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: House built in 1952. Other information n/a. Were sewage odors detected when arriving at the site? ❑ Yes ® No 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M Sey`e C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2.50' +/ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer pipe appears to be in good condition. No signs of leakage. Septic Tank(locate on site plan): Depth below grade: 2.0' Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Tank cover 9" below grade with 1.5'riser. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1,000 GALLON Sludge depth: APPROX. 3"+/- Distance from top of sludge to bottom of outlet tee or baffle APPROX.31"+/- Scum thickness APPROX. 4" Distance from top of scum to top of outlet tee or baffle APPROX. 18" Distance from bottom of scum to bottom of outlet tee or baffle APPROX. 5"+/- How were dimensions determined? MEASURED IN FIELD 30 Dunn's Pond Road-T5lNSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,y Subsurface Sewage Disposal System Form 41y sve C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank appears to be structurally sound, tees are in place, water level in tank is 3.2'deep approximately 0.8' below invert of outlet pipe. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityffown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A 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.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No D-Box present. 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.): N/A Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection 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: Type: ® leaching pits number: 1-1,000 gallon ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit appears to be working properly, no signs of ponding and vegetation is normal. 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004' Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 1N C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today real Estate 01/05/08 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A 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: N/A Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cunt.) 30 Dunn's Pond Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. F rya 0-N 6AC-K 6 R z A 3 - LA1. 15 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form G A, SV ey`e. C. System Information (cont.) 30 Dunn's Pond Road Property Address Hyannis MA 02601. Cityrrown State Zip Code Today Real Estate 01/05/08 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. =23'+/-,t GIS Contour Maps indicate that the ground elevation is approximately at elevation 52.0' +/-, approx. 29'+/-above the groundwater table. 30 Dunn's Pond Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Town of Barnstable Op THE 1pk Regulatory Services snxxsrnsie Thomas F. Geiler,Director 9$ 039i . `�g' A,E Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 568-790-6304 This septic system 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. u .UqCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 30 Dunns Pond Road Hyannis, MA 02601 Owner's Name: David Valentine Owner's Address: Date of Inspection: May 2. 2005 E Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford � ? Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 � Telephone Number: (508)862-9400 -- u� e CERTIFICATION STATEMENT STATEMENT ;z "o I certify that I have personally inspected the sewage disposal system at this address and that the info ation reevorted-i below is true,accurate and complete as of:the time of the inspection. The inspection was performed ased on my co training and experience in the proper function and maintenance of on site sewage disposal systems. am a IS8P r— rn approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste ✓ Passes Conditionally Passes Needs rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: May 4. 2005 The system inspector shall sub 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 Continents ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2. 2005 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to,determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. f 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Dunns Pond Road Hyannis. MA Owner: David Valentine Date of Inspection: May 2. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 Dunns Pond Road Hyannis. MA Owner: David Valentine Date of Inspection: May 2, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate.sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): -------gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 3 years ago-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 12129193-der as built card Were sewage odors detected when arriving at the site(yes or no): 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: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2. 2005 BUILDING SEWER'(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 22" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs_ofleakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2. 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: _ gallons Design Flow: gallons/day Alann present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None found (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Dunns Pond Road Hyannis. MA Owner: David Valentine Date of Inspection: May 2. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: a overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach nit had 1'ofliauid on the bottom. The scum line was approximately at the sane level There did not ani2ear to be any signs offailure. The bottom to grade was 8. The cover was 16"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Dunns Pond Road Hvannis. MA Owner: David Valentine Date of Inspection: May 2, 2005 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. Q` (jAuk � a q 6 a 3a` 13� 10 Page 11 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Dunns Pond Road Hyannis, MA Owner: David Valentine Date of Inspection: May 2. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) '� ✓ Checked with local Board of Health-explain: topnoggraphic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 25+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 ' a70- 00/ 0 0 R 5 �0.� FE$.. ....30.-00 No.. 1- .... APPW)VED THE COMMONWEALTH OF MASSACHUSETTS Barnstable Conservation Department BOARD OF HEALTH .'Z _>y — SZ TOWN OF BARNSTABLE Si 94d Date Appliratiuit for Bi-nVaiial Wurku Tunutrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: XXXXXXXXXXi> XXXX 30 Dunns Pond Road Hyannis -••-----•--------------•-----•--•-•------•--•-•-------.......-----------------------•-------•---•. -•----•--------••----•----•-•--•-•-•--•----------------•-...........--...............---•-•-•••••. Location-Address or Lot No. Thomas_Tvszkiewicz ._.. Owner Address W J .P .Macomber Jr . Installer Address Q Type of Building Size Lot---------------_----_-._..Sq. feet Dwelling-X No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Ga Other fixtures ------------------------------- - - W Design Flow...........................................gallons per person per day. Total daily flow..------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter.---............ Depth_--.--_-_------- x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...-..-------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. l----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ GXq Test Pit No. 2................minutes per inch Depth of Test. Pit-------------------- Depth to ground water........---............. P4 ------------------------------•-------------------------------------------------•--•....................--••--------•-•----•-•-•-•-•••----•----.....--•.---•. 0 Description of Soil....................................Sand & Gravel -----------------------------•-••---•--•-----•---•---•------•-----•-•-•••••--•--••••-----•--._...._.. x c, x ----••--------------------- -------------------------------------------------------------------------- --------•-----•-------------------------•----••------•••-----•--••----------------•-•----•....... U Nature of Repairs or Alterations—Answer when applicable...Omit._-c e s.s_po o l s . I n s t a 11 l-10 0 0 g-a-1•lon---t-a-nk---1---d-is#it-i-bu*,i-p&n---fax---I--.-1m0.0---- .-.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ed by th bo -d of health. Signed .... . .. . ...7eiss ........... .............................................. 3 ....... Date p� ApplicationApproved By .............. ... - ................. . .............. . ............................... Due Application Disapproved for the following reasons: ............. . .............. ... ........................................................................... ......... ............ . ..................... .......... ....................... .. ................... . .............. ........................................ Date PermitNo. ....L... ........ 0 5 .................. Issued ........................................................D. ........ Daze J, `JJ- �-7D , � � �� 3 0.0 0 No...l. ./ FRzA.... ti THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH S? TOWN OF BARNSTABLE Aliji iratiou for Eli-spntitt1 Wurk,i Tomitrurtion Hermit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: XXTKXXXXXXXtXKXK 30 Dunns Pond Road Hyannis .......................•-----•--............----------------------------....--•.............-----• ------•-------•--•-•--•-•---•-----•-•-----•-------•----•---.........-•------....----•-----....---- Location-Address or Lot No. Thomas Tyszkiewicz ......................-.......................................................................... ---------------------•--------•--•--•--••--•--•--•-•--•-•-----••--.....----....------..........._. Owner Address W J.P.Macomber Jr. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling X No. of Bedrooms..........._--------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers a YP g ---------------------------- P ( )._— Cafeteria ( ) d Other fixtures --------------------•------------•-----•----.._...... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width________________ Diameter..-------------- Depth................ x Disposal Trench— No. _................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter-___-___-_..._-:____ Depth below inlet.................... Total leaching area..................sq. ft. ' Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by................ ......................................................... Date------------------....------------•--- ,� Test Pit No. I________________minutes per inch Depth of Test Pit_________-_-_-.___-• Depth to ground water...__._.___-____--___.-. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------------------------------•------------------------------------------•----•••----------.................--••------•---------------............----.----- 0 Description of Soil....................................Sand & Gravel --------••-•-------------------------------------------------------•-------•-•---.....-----•--••-•-•------------------_.. (�j ----------------------------•---------------------------•-----------------------------------------------------------------...-------------------------------------------•---•......---•----.. W ----- ---------------------------------------------------------------------------------------------------------------------------------•------------••-•--•---------------------•---•---.............. U Nature of Repairs or Alterations—Answer when applicable---0mit Cesspools . Install 1-1000 .--- ^rl...t-arld...1 _rl i.---t-r-ibaJ+i.TI:Lr,,n...bax... .......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the g he,bo rd of health. system In operation until a Certificate o Compliance as beenIssued by t Si ned ., �'° '/"! -! -............................... -- ........... 12/21/93 .......... .......................... Date Application Approved By -----------CJ -..-sue--,` 'c .s`.- ---------- - Date Application Disapproved for the following rearons: ------------------------------------------------------- ....------...........---..........------------------------------ ---- --------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- CCpp Dare PermitNo. 1...a.. 70-?------------------------------ Issued ...-------------------------------------:.------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�extifi ate of 011ju plianre THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) by ... J.P.Macomber ter. ..............................__--------------------------.----------.......----------------------------------------....------------------..................................................................................... 30 Dunns Pond Road Hyannis . Installer at --------------------------------------------------------------------------------------- -------------------------------------..--------------------------------- ----------- --------......-------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... .-�... �----------------- dated ----------------------------------........._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ... --- :.!.. -. - ._...... Inspector - _-_--- ----- ------- --------------... CJ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq TOWN OF BARNSTABLE No...1..�.-•.��� FEE.... -•---..30 00.. Ropooal Workii Tunitrudion rrutit J.P.Macomber Jr. Permission is hereby granted ---------------------------------------------------------------------------- to Construe ( or Repair �Xx an I v rl al.Sewage Disposal System Danns E one ) oad 'yainis lip age No...--•-•-------------•--•------------------•.---•-------------- street r, as shown on the application for Disposal Works Construction Permit No.. 70�___ Dated____ -_ '. ._...... ----....----•-.--•--e.....---- � ...............•-•-----------------•-------------•-•--- �DATE-------- c�- ��--•---••-------------------------•--. Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND ..SEPTIC SYSTEM PROFILE BROUGHT TO WITHIN 6"OF FINAL GRADE Flaheity Environmental Services EL. 58.0' EL. 56.0' (not to scale) INSP. PORT W 13" OF GRADE CLEAN SAND P.O. Box 331 2"of e"to Z" DOUBLE WASHED EL. 56.0' - Hamich, MA 02645 4"CAST IRON or EQUIVALENT LENT PEASTONCOR GEOTEXTILE 774.994. 1166 ' MIN. PITCH 1/4" PER FOOT FILTER FABRIC ; 4"SCHEDULE 40 PVC PIPE 4"SCHEDULE 40 PVC PIPE ,+ FLOW LINE • VENT IF REQUIRED 111ist 216 be/eve/1 • :. �t' ' L.EXIST. 14„ ® .•.. �_ . ,00000o0oc —� 00000 ° Ooo .' 0000 •'' EL.EXIST 00000 0000c EL. o00 000 0000c EL 53.03' 000 0 00000000 0°0°0°0oc L.53.2' ° o°o° °o°o°o° o°o°o°o°c 2.0' o 0 0 00 0 0 0 0 0 0 0 0 • GAS BAFFLE EL.53.0' 000000000 000000 M-1 (H-20D-BOX) o°o°000° °o° °o°o°o a' °o°o°o°o° o 00 0 0 0 •• a ' °o°o°o°o° EL.51.0' 1 • .`° • •. 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM S' '` �' •` �'' MECHANICALLY COMPACTED (2) 500 GALLON H-20 CHAMBERS 1000 GALLON SEPTIC TANK 6.0' (DATUM: ASSUMED) (EXISTING) „ WITH 4'STONE AROUND IN A 4 to 1�L„ DOUBLE WASHED STONE 12.83'X 25'X 2'CONFIGURATION LEL. BOTTOM OF TEST HOLE EL. 45.0' 45.0 USGS ADJUSTMENT: N/A LocArioNMAP _GROUNDWATER ELEV: N/A N Tx 20 58 BHS LOCUS c O BENCHMARK: ('I'B3t Me/n St O TOP OF FNDN 'co / EL. 60.0' Lp EXIST, L.P. 'co / EXIST. S.T. a O 58 r. 0� / O + NTS ®� EXISTING OF 2 BR DWELLING '''`�:1 <�:+ ate LOT 19 i• O :f� / MAP 270 LOT 21-2 PORca `''•" o ®�4� r I TH-2 ~ X I v (I 129,16, 11 DATE.-111=019 RE ISED. LEGEND SITE AND SEWAGE PLAN 6--6 6 GAS LINE FOR w w WATER LINEB 8I B EXCAVATION, INC./ RENATA VIEIRA -E E—E--E 6 EXIST. ELECTRIC 3O DUNN'S POND ROAD 99 EXIST. CONTOURS _ ' (HYANNIS BARNSTABL MA IE, ————— 99 PROP. CONTOURS SCALE • 1" - 3 0 U,6 W16 U,g UNDERGROUND UTIL. REP LCP 10614-E PAGE 1 OF2 .......... .......................................................................................................................................................................................... ............................ ..................I.................................................................... ................................................. ............................................................. ............................................................................................................................................................................................................................................................................. ...................................................... GENERAL NOTES DESIGN CAL CULA TIONS S YS TEM DETAIL Flaherty Environmental Services 1. ALL PRECAST COMPONENTS TO BE H-10 I A 0. Box 331 RATED UNLESS OTHERWISE SPECIFIED. Harwich, MA 02645 DISTRIBUTION BOX AND ANY NUMBER OFACTUAL BEDROOMS 2,, 774.994.1166 COMPONENTS WITH ANY AN71CIPA TED VEHICULAR TRAFFIC TO BE H-20 RATED. GARBAGE DISPOSAL UNIT NO 2. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OFA GARBAGE TOTAL ESTIMATED FLOW GRINDER. (110G4L/BR1VAYX2BR) 220 GALAVAY� 3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 440 GAL. 4. ALL CONSTRUCTION TO CONFORM WITH 25' - 310 CMR 15.000 AND ALL OTHER SIZE OF SEPTIC TANK 1000 GAL. (EXISTING) APPLICABLE LOCAL, STATE AND FEDERAL CODES AND REGULATIONS. SOIL CLASSIFICATION 5. INSTALLERICONTRACTOR TO REVIEW& VERIFY ALL ELEVATIONS AND DETAILS DESIGN PERCOLATION RATE <2 MINAINCH AND REPORT ANY DISCREPANCIES TO . . I DESIGNER PRIOR TO CONSTRUCTION OR EFFLUENT LOADING RATE 074 GALIDAYFT- 12,83' ASSUME ALL RESPONSIBILITY, LEACHING AREA 6. INSTALLER/CONTRACTOR IS (2)x(25.0'+ 12.83)(2) = 151SF RESPONSIBLE FOR MAINTAINING SAFE 25.0'x 12.83' =320 SF WORK AREA, VERIFYING ALL UTILITIES 471 SFx a 74 =348 GPD AND NOTIFYING "DIG SAFE" (1-888-344-7233) 72 HOURS PRIOR TO USE(2)500 GALLON H-20 CHAMBERS WITH 4'STONE CONSTRUCTION. INA 12.83'X25'CONFIGURATIONASDIAGR4MMED 7. ANY CHANGES TO OR DEVIATIONS FROM THIS PLAN MUST BE APPROVED IN RESERVE LEACHING CAPACITY NIA WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3'PER 310 CMR 15.000 UNLESS SHOWN PER PLAN (NTS) 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRYAND FILLED WITH CLEAN SAND OR REMOVED SOIL EVAL UA TION AND REPLACED WITH CLEAN SAND. TESTHOLE#1 TPT#19-202 TESTHOLEW TP7#19-202 10.ALL COMPONENTS TO BE PROVIDED Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator.- 'I David D.Flehertv Jr.,RS,REHS OF WITH WATERTIGHT ACCESS PORTS SE#2755 SE#2755 " BOH Witness. David Stanton,RS BOH WRness. David Stanton,RS WITHIN 6 OF FINISH GRADE. Date. Navember8,2019 Date., y Novembers,2019 DA 11.ALL SEPTIC TANKS, DISTRIBUTION BOXES AND PIPING TO BE INSTALLED HE WA TER TIGHT. 7H-1 ELEV.56.0' 11 TH-2 ELEV.56,0' 12.NO KNOWN WETLANDS OR WELLS 0*-10' A LS 10YR&2 01-10" A LS 10YR&2 T WITHIN 150 FEET OF PROPOSED MITAId LEACHING. 13.THIS IS NOT A CERTIFIED PLOT PLAN 10'-27' B Ls IOYR516 i 10--27- B LS IOYR516 AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR 7 ceifffy that on November 12,2002, have passed SITE AND SEWAGE PLAN jy) Pam BUILDING PURPOSES. E the examinagon approved by the Department of 14.LOT IS SHOWN AS ASSESSOR'S MAP 270 Entftnmenlal Protection and that the above analysis FOR LOT 21-2. has been performed by me consistent with the 8 & 8 EXCAVATION, INC./ 27"-132' C MS 2,5YtV6 27"-120" C MS 2.5Y required ftining experg- and experience described 15.LOCUS PROPERTY IS LOCATED WITHIN In 3 10 CMR 15.0 18(2). RENA TA VZEZRA AN AQUIFER PROTECTION DISTRICT 30 DUNN'S POND ROAD (ZONE II). (HYANNZS) BARNSTABLE, G.W.ELEV.NIA G.W.ELEV."MIA 45.0' BOTTOM TH-1 ELEV. MA BOTTOM TH-2 ELEV. 46.0'. PAGE20F2 DATE.•1111212019 ...................................................... ...................................................... ................................................................................ .............................................................................. ---...................................................... ..................................... ..... ............ .... ............................................................................... ......................................................................-.................................................................................................................................................... .................................