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0193 FAWCETT LANE - Health
.1 93 Fawcett Lane - Hyannis"' F/R A = 270 106 ' l `I r 4!1` i f TOWN OF BARNSTABLE �( LOCATION I 1 AGJCgJ± Lnne SEWAGE # 2-003' l VILLAGE 14VA"Ii' ASSESSOR'S MAP&LOT�3� INSTALLER'S NIIAME&PHONE NO. e-,a1. i A e- y fC 10 SEPTIC TANK CAPACITY 1 Q60 LEACHING FACILITY: (type) 1 cev 4 (�a) �c (size) NO.OF BEDROOMS \\ ,^n BUILDER OR OWNER eOb A Y",WS-k PERMITDATE: /0 - 03 OMPLIANCE DATE: 1011103 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 41114. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 4/4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) �� 1 Feet' Furnished by cC� � TP )o s . L a a T f Commonwealth of Massachusetts °?�LL)_ /0(v - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'M e 193 Fawcett Lane Ji Property Address s Regina Schlegeter Owner Owner's Name r required for everyy information is H annis ✓ Ma 02601 10/27/2020 . 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 A. Inspector Information S filling out forms '� on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co � Company Address Centerville Ma 02632 Cityrrown State Zip Code low 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com 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 15.000); 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 10/27/2020 Inspector's Signatur 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.7/26/2018 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 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 193 Fawcett Ln Hyannis is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 37' leach trenches. . Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain_below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is Hyannis Ma 02601 .10/27/2020 required for every y 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 system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply.. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ N 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.7/26/2018 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 —u 193 Fawcett Lane Property Address Regina Schlegeter Owner Owners Name information is H annis Ma 02601 10/27/2020 required for every y page. City/Town 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 ❑ E Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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. 0 ® 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. ❑ o 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 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 t5insp.doc•rev.7/26/20111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every y H annis Ma 02601 10/27/2020 page. City/Town 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 Forth:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is Hyannis Ma 02601 10/27/2020 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Description: 5 Number of current residents: 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 years usage(gpd)): Detail Sump pump? ❑ Yes ® No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. City/Town 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 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 below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. Cityrrown 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 repaired 10/9/2003 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. 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 � s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7' Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7/26/2018 rdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M e' 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. 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): I Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis annis Ma 02601 10/27/2020 page. Cityrrown 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 alarm 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 oil 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.): Distribution box was level and in good condition with no rot. Water level was even with 2 outlet inverts with no signs of past backup. Cover is on a riser t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 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 pump chamber, condition 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: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 37' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/262018 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 e 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is Hyannis Ma 02601 10/27/2020 required for every y page. Cityrrown 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.): s.a.s. consists of 2 x 37' long leach trenches 4'wide and on 2'stone. 1 of 2 trenches was video inspected from d-box( unable to get camera down other trench because inlet pipe is blocking the end, flow appeared to be even with speed levelers.), perforated pipe was found clean with no standing water or signs of past overloading. 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2W018 Title 5 Official Inspection Farm: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 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name . information is H annis Ma 02601 10/27/2020 required for every y page. City/Town 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 of hydraulic 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. Citylrown 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 t Z 0 � AI 131 Z_l AZ /S �� zf_�I, A3 L13 Q3 1& t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is Hyannis Ma 02601 10/27/2020 required for every y page. Citylrown 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. 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 Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Fawcett Lane Property Address Regina Schlegeter Owner Owner's Name information is required for every Hyannis Ma 02601 10/27/2020 page. Cityrrown 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 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 1S APR, 10. 2009 9: 54AM NO. 681 P. 2 O4INE TOWN OF BARNSTABLE 8.6ilding � application Ref. 200805761 _ aARxsra>ar.E, i Issue Date: 11i06/08 Permit MASS. 9 1639. Applicant: SCHLAGETE REGINA R Permit Number: B 20082497 M Proposed Use: SINGLE FAMILY HOME Expiration Date. 05/06/09 Location 193 FAWCETT LANE Zoning District RB Penriit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 270106 Permit Fee$ 25.00 Contractor PROPERTY OWNER Village HYANMS App Fee$ 50.00 License Num Est Construction Cost$ 100 Renearks I APPROVED PLANS MUST BE RETAINED ON JOB AND ELIMINATING 2 BEDROOMS 13Y OPENING UP TO 5-CASED OPENIN�S THIS CARD MUST BE KEPT POSTED UNTIL FINAL ELIMINIATING KITCHEN ON SECOND FLOOR INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Rceord: SCHLAGETER,REGINA R BUILDING SMALL NOT BE OCCUPIED UNTIL A FINAL Address: 193 FAWCETT LN INSPECTION HAS BEEN MADE. HYANNIS,MA 02601 �� Application Entered by: PR Building Permit Issued By: T141S PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY OR PERMANENTLY. ENCROAC14SMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST 13E INSPECTED AT THE THROAT LEVEL BEFORE 17MST FLUE LINING TS INSTALLED. 3.W11UING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). 1 i S 1TRE ET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 i 1 i 2 2 2 3 ' fi► 1 heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health Town of.Barnstable Health Inspector oFt t Office Hours o Regulatory Services 8:30—9:30 II �, Thomas F.Geiler,Director 3:30—4:30 * snxtvsrna�, r Public Health Division ATFO�'�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT—SEPTIC QUESTIONNAIRE Date: 9/11/08 1. General Information: Size of Property: 2157 Sq. ft. Address: 193 Fawcett Lane Hyannis,MA 02601 Map 270 Parcell06 ' Name: Regina R. Schlageter Phone#: 508-364-6154 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? �� (� If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. how all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or. NO- 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY - The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q;/health/wpfiles/amnestyapp d f D i 61 cl b7n OV E 1 a i 1 y7 7 i i j ZJ l i i •� s] lz C43 3 Ono i t f � t R 3 y , f S.ryo { f t � 5 •i"No d 3 ) r t i t i 1 r tnaat�e } - t y i Y .ja No. OLW.3 Fee �® THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASS ACHUSETTS Z(pprication for Miopotar bpotem Con!Aruction Permit Application for a Permit to Construct( _ )Repair Upgrade( )Abandon( ) 0 Complete System ❑Individual Components Location Address or Lot No. AA � Owner's Name,Address and Tel.No. Assessor'sMap/Parcel -'Of� �� � `'tom, 0,110- o tes Installer's Name,Address,and Tel.No. 5-8 F—W-601 y Designer's Name,Address and Tel.No. Type of Building: jDuy Vr\l I'PN Dwelling No.of Bedrooms _ Lot Size. 600_sq.ft. Garbage Grinder( ) Other 'Type of Building C t�D�No.of Persons Showers( G.)—Cafeteria( ) Other Fixtures Design Flow `4 �/0 gallons per day. Calculated daily flow Lfq 6 gallons. Plan Date Q— Number of sheets Revision Date d4a Title �' Size of Septic Tank (0oa Type of S.A.S. Desc ' tion of soil; C O t9 G St° gly r Nature of Repairs or Alterations(Answer when applicable) 2-^ 34) X 4X2� 0 rehc�eS 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 Envir ental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by Bo d of bfeallh. Sig ed Date /� ^ 0 3 Application Approved by Date Application Disapproved for the following reasons Permit No. x40CD3 �� Date Issued 10 tiv O No. C7,1 <_ ) % - Fee r ;! THE COMMONWEALTH OF MASSACHUSETTI-* ` ; nteredincomputer: � PUBLIC,,HEALTH DIVISION -TO,WN OF BARNSTABLE., MASSACHUSETTS Yes x7 ' 2ppYicatfon for 33i.5pool *VZtem Construction Permit Application for a Permit to Construct( )Repair(N Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. m A�S Owner's Name,Address and Tel.No. , Assessor's Map/Parcel �✓- ` , -} a_A e Installer's Name,Address,and Tel.No. 5-6 1�-_ �' -601 Designer's Name,Address and Tel.No. Li 3' y;re s+ Type of Building: .flvy bvr\1 '(i'1 A 09.33'-- Dwelling No.of Bedrooms Lot Size 10160 sq.ft. Garbage Grinder( ) Other 'Type of Building C No.of Persons Showers( L)—Cafeteria( ) Other Fixtures ' Design Flow Y y o gallons per day. Calculated daily'flow b gallons. Plan Date — �� - G Number of sheets f };`Revision Date d/« a Size of Septic Tank fOOO Type of S.A.S. Descri tion of Soil, L O e)C se. SlP^\ � 77" Nature of Repairs or Alterations(Answer when applicable) 3 , t{ l(Z r e✓it e S 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 Envirpnmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by Bo d of Flea nth. Sig ed Date lb 6 3 Application Approved by Date Application Disapproved for the following reasons Permit No. aC!�2 3 'T 41 90 Date Issued /D 6 D --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by_XeA K k°n v— at V° � V rwL,)C e14 L A v k trt,,„;s has been constructed in(accordance r with the provisions of Title 5 and the for Disposal System Construction Permit No.!ZW L-d-1C-s dated 0 9. 10 Installer Designer The issuance of this permit all not be construed as a guarantee that the system illfune'tion ass des''g ed. f y Date fU�9 QY Inspector1d . .+ `•-�' - ---------)------------------------------ No. �3 �` Fee 55 y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mi5po5a1 *p5tem Congtruction Permit Permission is hereby granted to Construct( )Re air(V.)Upgrade( )Abandon( ) System located at I9 3 �VX P F � , go>J I'5 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditi(b ! onns. Provtd d:Construction ust be completed within three years of the dais p t. Date: I / 3 Approve yy TOWN OF BARNSTABLE 1 LOCATION 3 FtaGJt gdt LK49- SEWAGE # 2MS' t9L VILLAG"44A/f ASSESSOR 'S MAP& LOT d INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) 1 CLA (size).' NO.OF BEDROOMS ^� BUILDER OR OWNER PERMIT DATE: Q3_COMPLIANCE DATE: 101 IL03 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility WA 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) �� l4 Feet Furnished by i O i?�ov S,-hale �5w 2�� ®t"r =2 �x q3 F 6 Town of.Barnstable Health Inspector oFt►+e tp� Office Hours •. o Regulatory Services 8:30-9:30 Thomas F.Geiler,Director 3:30—4:30 * BMW9rABM • T 1.1* _ TT_ 7 1_ 7l* ! • 9� ��� rUD11C nealtn Division Arlo �A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT—SEPTIC QUESTIONNAIRE Date: 9/11/08 1. General Information: Size of Property: 2157 Sq.ft. Address: 193 Fawcett Lane Hyannis,MA 02601 Map 270 Parcel106 Name: Regina R. Schlageter Phone#: 508-364-6154 2a. How many bedrooms exist at your property now? _ 2b. Are you planning to add an bedrooms.y p g y � t� 0 If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO. 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q;/health/wpfil es/amnestyapp aits.I L-A -- cl Cl a r 1 a a F a V , ----------- I J-1 iA J { u - � f I. 4 t 1 I I a f I x 1 Town of Barnstable Health Inspector �tME t Office Hours o Regulatory Services 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 • snxxsrABLF, « 9� MASS.: - Public Health Division Argon Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT—SEPTIC QUESTIONNAIRE Date: 9/11/08 1. General Information: Size of Property: 2157 Sq.ft. Address: 193 Fawcett Lane Hyannis,MA 02601 Map 270 Parce1106 Name:Regina R. Schlageter. Phone#: 508-364-6154 2a. How many bedrooms exist at your property now? 4 2b. Are you planning to add any bedrooms? NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protzq on Zone? � -v a? ns ;. :X C"? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to p tic sup&well-sue? '. ramCD 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? ' 7. Is a disposal works construction permit on file? YES or NO - 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO... 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or' NO FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: --- Date: Q;/health/wpfiles/amnestyapp E {. (� 5 d S 3 i d Ai ;r CC 1 ,., tom•, i 3 9O 3 � �c nG S �j 3 E i ,a Ni a � i V r' s d. t 1 ate__.____.__ 3• - j�--� 5 ' tL; 61 h 0Uic- =r' C' '-r4 lE h - 3 t j i i M - 2 TROY WILLIAMS RECEIVED SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection TOWN OF BARNSTABLE (508) 385-1300 FABLED INSPECTION 19 Hummel Drive HEALTH DEPT. South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ProperfN Address: 193 Fawcett Lane Hyannis,MA Owner's Name: Heather Marsh Owner's Address: 193 Fawcett Lane Hyannis,MA 02601 Date of Inspection:. August 6,2003 Name of Inspector: . Troy M.Williams O Company Name: Troy Williams Septic Inspections Mailing Address:. 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systenv Passes Conditionalh• Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: !s;z' , Z,. 6L_ Date: 8 /6 /a 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Ilealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I or[[ Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that an f the failure criteria described in 310 OKIR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not aluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to b eplaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board health, will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statement f"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank( ether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure i ' minent. System will pass inspection if the existing tans:is replaced with a complying septic tank as approved the Board of Health. •A metal septic tank will pass inspection if it is structurally sou ,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 bre ut or high static water level in the distribution boa due to broken or obstructed pipe(s)or due to a broken,settl or uneven distribution box.System will pass inspection if(with approval of Board of Health): roken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The s ern required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass insp ton if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health ut order to detennine if the system Ts failing to protect public health, safety or the environment. I. System N ill 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 envir nment: _ 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 Su ier,if any)determines that the system is functioning in a manner that protects the public health,s ety and environment: _ The system has a septic tank and soil absorption system AS)and the SAS is within 100 feet of a surface eater supply or tributary to a surface water suppl . The system has a septic tank and SAS and the AS is within a Zone I of a public water supply. V The system has a septic tank and.SAS the SAS is ithin 50 feet of a private water supply well. The system has a septic tank and AS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Meth used to determine distance "This system passes if the ell water analysis, performed,at a DEP certified laboratory, for coliform bacteria and volatile org c compounds indicates that the well is free from pollution from that facility and the presence of amm to nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria ar ggered.A copy of the analysis must be attached to this form. 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: 193 Fawcett Lane Hyannis,MA Owner: Heather Marsh Date of Inspection: August 6,2003 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 a/4 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%a day flow �[ Required pumping more than 4 times in the last year LVQTT 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. _3Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. "M 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. 4d, 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 resence of ammonia nitrogen and nitrate nitrogen is equal to or,less than 5 ppm,provided bat no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YF S (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. large Systems: To be considered a large system the system must serve a facility with ad gn 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 crit a above) yes no — _ the system is within 400 feet of a surface drink' water supply the system is within 206 feet of a tribu to a surface drinking water supply the system is located in a nitrog sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water su y well If you have answered"yes"to a question in Section E the system is considered a significant threat,or answered "yes"in Section D above th arge system has failed.The owner or operator of any large system considered a significant threat under tion E or failed tinder Section D shall upgrade the system in accordance with 310 CMR 15.304.The system or should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the followitte: Yes No ✓ _ P. r ing information was provided by the owner.occupant, or Board of I iealth _.✓ 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? — A,Iq 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 t�nk 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 I 1 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION .Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of inspection:Heather Marsh August 6,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): V Number of bedrooms(actual): Y DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x q of bedrooms): yy& Number of current residents: 1 Does residence have a garbage grinder(yes or no): wo Is laundn on a ,rparatc sewage system(yes or n,,) V- (if yes separate inspection required) Laundry system inspected(yes or no): AA Seasonal use: (yes or no):vo Water meter readings,if available(last 2 years)jsabe(gpd)):_a i= 0 3 3 L�oo� it, o i_o i 32�,,� Sump pump(yes or no): va Last date of occupancy: C_ C_�T,L.r 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 syst (yc:s or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL. INFORMATION Pumping Records Source of information:N—o—��,.w Was system pumped as pan 6f the inspection(yes or no): _&O If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ZSeptic tank,distribution-be rt,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all (components.date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):Alo ..i i y. 91 .. 6 Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 BUILDING SEWER(locate on site plan) Depth belu%% grade: /8"f Materials of construction: ,,-,cast iron _40 PVC other(explain): Dkiance fron, pm ate water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: )`/' 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: __ (co o Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: Z ' 2 Scum thickness: 41,, 147 Distance from top of scum to top of outlet tee or bafllc: _ C" Distance from bottom of scum to bottom of outlet tee or baffle: Flow were dimensions determined: )q.6,. Comments(on pumping recommendations, inlet and outlet tee o__r baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): �61....r.-.f=_Z ��- > f•L/t.r.t 1 L. ✓l L., /Vo Zvi J l' - —, :. ._sue---/Lw l.` S.� u.r._.JCY✓�C N CREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_ p ethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom of outl ee or baffle: Date of last pumping: Comments(on pumping recommendatio ,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence o eakage,etc.): 7 h Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection) ate on site plan) Depth below grade: Material of construction: concrete metal fiberglass yethylene other(explain): Dimensions: —- Capacity: gallons Design Flo%%: _ gallons/day Alarm present(yes or no): Alarm level:_ Alarm in working ord yes or no): Date of last pumping: Comments(condition of alarm and t switches, etc.): DISTRIBUTION BOX: (if present must be opened)(lo a on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to lets equal,any evidence of solids canyover. any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump chamber,c ition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 SOIL ABSORPTION SYSTEM(SAS):_V. (locate on site plan,excavation not required) If SAS not located explain why: Tyv/pe leaching pits.number: ► 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.): I s-�..�I-.._� Abu✓� i .I- i►�..iw�- o.,F �I.c t 1 �.c =� ,v. S r✓t ��i 6 r., w o S �i. �. CA r-V-. i 7 d: L ✓r am CESSPOOLS: (cesspool must be pumped as part of inspection)(1 ate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: _ Depth of scum la\er. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or n Comments(note condition of soil,sign hydraulic failure, level of ponding,condition of vegetation,etc.): i PRIVY: (locate on site plan) Materials of construction: Dimensions: Xfailure, level Depth of solids: Comments(note condition of soil,signs of hydra 'c 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: 193 Fawcett Lane Hyannis,MA Owner: Heather Marsh Date of Inspection: August 6,2003 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. 01, ' z� 2y 'c. P k 10 Page 1 I of I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane Owner: Hyannis,MA Date of Inspection: Heather Marsh August 6,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet - - Adjusted high ground water elevation _ feel Please indicate(check)all methods used to determine the high ground "ater 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 I lealth-explain:Checked with local excavators, installers-{atta_ch: documentation) ✓ Accessed USGS database-explain „ I , u.S G i �yp� You must describe how you established the high ground water elevation: --�---qH'-r. hr�,L-f_._..- vo✓K.t t�_w�-t-�- / - - .. _ of .. This report has been prepared and the system inspected 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 TOWN OF BARNSTABLE LOCATION 1� 3 f'�� E-c- - - SEWAGE �f'�f/� VILLAGE I'�`+i h +t`• ASSESSOR'S MAP & LOT-2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ./3j� c,, 4— (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 Jw`; (7 ; :„�.., �`�z6/oo _ __.. O � � �. � � . '�. �- � � _ � . 7 to ,6 TROY WILLIAMS _ SEPTIC INSPECTIONS110 Certified by MA Department of Environmental Protection /� � 5\©8) 385-1300 19 Hummel Drive South Dennis, MA 02660 P�4f" o 000 r�A"-7 a � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: M 3 Name of Owner k o Fs 4-,4-< Address of Owner: CeG jg r- c.z C. r c k o Date of Inspection: ,S//26 /Op /8 3 Name of Inspector(Please Print) Troy Williams 14-1 c n n. S /lit U 26 o 1 am a DEP approved system inspector pursuant to Section 15.340 of T-rtle 5(310 CNIR 15.000) Company Name: Troy LWilliams Septic Mailing Address: Mang Address: 19 Hummel Drive, So. Dennis, MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 1 // Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fail Inspector's Signature: �JC,Y�L Date: S �Z A 0 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttte system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS -� Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 9/2 /9R e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prop"Address: 193 Fawcett Lane,Hyannis,MA Own": Cicko Estate Dace of Inspection: May 26, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: /V I 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. Indicate yes,no, or not determined(Y, N. or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 193 Fawcett Lane,Hyannis,MA Property Address: Cicko Estate Owner: Dace of Inspection: May 26, 2000 \ C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:,V/4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WfTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 56 feet of 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 W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 193 Fawcett Lane,Hyannis, MA Cicko Estate Property Address: May 26, 2000 Owner: Date of Inspection: D. SYSTEM FAILS:Al�9 You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due•to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: A/M 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No . the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST 193 Fawcett Lane,Hyannis,MA Property Address. Cicko Estate Owner: Date of Inspection: May 26, 2000 Check if the following have been done: You must indicate either "Yes" or "No' as to each of the following: Y No ;L% Pumping information was provided by the owner, occupant,or Board of Health. _ None of the system components have been pumped-for-at least two weeks and-the system has been•receiving-normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. IVIJ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. �[ _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption.System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper maintananceof Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop"Address: 193 Fawcett Lane,Hyannis,MA Owner: Cicko Estate Date of Inspection: May 26, 2000 RESIDENTIAL: FLOW CONDITIONS Design flow: //0 g.p.d./bedroom. Number of.bedrooms(design): y Number of bedrooms(actual): Total DESIGN flow yya - Number of current residents: / Garbage grinder(yes or no): Ato Laundry(separate system) (yes or no):AA); If yes, separate inspection required s y �s �3 fi�� °`"' `s v's Laundry system inspected (yes or no) p,., J, -A ,J4s 1itCA :6,/-V syy�,�,�..,;, Seasonal use(yes or no): A10 N} ` �"" „ _ Water meter readings,if available(last two year's usage(gpd):19-00 = /l,d�ij Sump Pump(yes or no): VV Last date of occupancy: c c.- ,ro;i, . COMMERCIALIINDUSTRIAL: A1119 Type of establishment: Design flow: opd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N6 r .. System pumped as part of inspection: (yes or no)NO If yes, volume pumped: gallons Reason for pumping: TY SYSTEM Septic tank/dim/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Of known)and source of information:_ 6,.-. ,ft ( u N„ ��. \+ µ,Qproz. iy6?. Sewage odors detected when arriving at the site:(yes or no) N- revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane,Hyannis,MA Owner: Date of 4ispection: Cicko Estate May 26, 2000 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:--V/Cast iron—40 PVC-V-/.ther(explain) .c- v Distance from private (water supply well or suction line N Diameter L/ Comments: (condition of y'qints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:Zconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age— Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sr $ Sludge depth: 5r" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: V 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: /6'' How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structuroHntegrity, evidence of leakage,etc.) Cp H "j _ 'ti o racy /b c. J So '.ak GREASE TRAP: ,9 (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: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address: 193 Fawcett Lane,Hyannis,MA Owner: Cicko Estate Date of Inspection: May 26, 2000 TIGHT OR HOLDING TANK:�(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: - Capacity: gallons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUMP CHAMBER: i'� (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.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane,Hyannis,MA Owner: Cicko Estate Date of Inspection: May 26, 2000 SOIL ABSORPTION SYSTEM(SAS):- (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: r / leaching pits, number: ) — 5 X 5 b�u C-/� f�� f ., leaching chambers, number:_ leeching galleries,number:_ leaching trenches,number, length: leaching fields; number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, si s of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Gam, CESSPOOLS: (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level.of.ponding, condition of vegetation, etc.) PRIVY:LV/A 1 (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.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Fawcett Lane,Hyannis,MA Owner: Date of Inspection:. Cicko Estate May 26, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i 3 revised 9/2/98 Page 10ot 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corn irrm4 Property Address: 193 Fawcett Lane, Hyannis,MA OM/Def: Cicko Estate Date of Inspection: May 26, 2000 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope.,/ Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site 1Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) tj L) i revised 9/2/98 Page II of II ASSESSORS MAP : 210 TEST HALE LOGS NOTES: PARCEL : `(J(p 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH 3 FLOOD ZONE : N0t� P�� SO I L EVALUATOR :b.�M6gffL R S, CS�. - IS PLAN, 1115 MASSACHUSETTS TITLE V & TOWN OF ti WITNESS : ► or BOARD OF HEALTH REGULATIONS. REFERENCE : G I����U�j DATE: I � 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RA :E : L ?wt�N�Iv�,�6 InoI(. SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO Lw-= Q,�q / �Y INSTALLATION. TH- I. 2b ( TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION S T a LU�M ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE J OV 0-/y DETERMINATION. € 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS W � 1 SPECIFIED OTHERWISE) LOCAT I ON MAP(NTS� ,a 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A s l-l GARBAGE DISPOSAL. Q�� f 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON q A BASE OF 6"OF CRUSHED STONE. I 7)_rU/ZT/,u� G AGH PiT Tv-8E PomP60� CRu5nb 4 FeMolJ.D .._.__. rya ._ FEn�� 5s36 SEPT I (, SYSTEM DESIGN 9) No. lTIN .w���..15d'oF PRoPo . 100. s .7 10� OA 700) of -8f-QAl, fi-r, —,6 ... FLOW ESTIMATE �37' 31 BEC?ROOMS AT GAL/DAY/BEDROOM - �7D GAL/DAY SEPT I C ETANK z: C � 7 GAL/DAY, x 2 DAYS - MO GAL �,y a USE I '� GALLON SEPTIC TANK —E0STIN/- '� Pt./C w/I�sz&IseFr- k IF o2 VN��1pS12E.D_ \ GA IJAWS ° SOIL A(SORPTION SYSTEM .T.P , • ["1 Sl,kfi, 5� SIDE AREA:_ 3� 7xZ� x111- yx2xzXo, )y i ( B&TTOM AREA:' x y x 0, SEPT I C� SYSTEM .: `SECT 14N ar S� T8M- TOP k \ 8z- to ; i 1\�i23 ' 6/e- Wasbed wip D,BOX q.960 G� -fix 3 ILCJ�cc� GAL y - /' /i Double WAShPcf j SEPTIC TANK mr •e✓ lnes)s 1'?- 37'L x y i� ,� �� Ta_�Ncr�E S n 7 `01f s. OF MASS^9 I/�`�-1--_G�`` ��.y2T_I'fUCC__��_._.__G[�'• ��, 2 b D RREN cti� N S I-TE AND SEWAGE PLAN . 1140 G�STER LOCATION : lqj r pi(e t,4AE ` s 0gN17ARIPN 17,03 PREPARED FOR : S U�U r DARREN M. MEYER R.S. SCALE : Zd p��N OF LA+r� ���� I���U� 43 VINE STREET DATE : q-1G�-03 �6) DUXBURY, MA 02332 DATE HEALTH AGENT (781) 585-0293 fiUIN rJ (hfj;