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HomeMy WebLinkAbout0203 FAWCETT LANE - Health 203 Fawcett Lane Hyannis A=270 107 I -i9-7- Commonwealth of Massachusetts Title 5 Official Inspection Form 3 Subsurface Sewage Disposal System Form Not for Voluntary Assessments �E 203 Fawcett Lane Property Address MD Fermanda Torres :. Owner Owner's Name informatlon is tom, required for every Hyannis �/ MA 02601 2-1-18 Cit (Town State Zip Code Date of Inspection page. y p 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. General Information n ozg onng out forms the computer. # ��` \\���`�����HICF. ss '% use only the tab �C'% key to move your 1. Inspector: s�- cursor-do not lames D.Sears JAMES m=_ use the return Name of Inspector key. Capewide Enterprises ' Company Name ' ! ROE 153 Commercial Street '`��A� ,5 !N SP"-G`\``�� Company Address Mashpee MA 02649 Cltylrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 6(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-3-18 ffipector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. r5ins.doc-raw.V 6 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 91, abed xed dH 99:1•Z t'0 gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Corner's Name information is required for every Hyannis MA 02601 2-1-1 B pa", Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The system is a 1500 Gal, Tank D Box and five chamber's. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tSins.doc rev.&16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 66 abed xed dH 99:2 2[OZ ti0 gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally passes(cont): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:subsurface Sewage oisposal system-Page 3 or 17 OZ a5ed xed dH 956E 860E b0 qad Commonwealth of Massachusetts Title 5 official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I D) 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 ❑ ® 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 610M is less than 6" below invert or available volume is less than'/s day flow �FA01,v6 ISins.doc-rev.U16 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 l,Z a5ed xeJ dH 99:2 81,0Z t70 9aJ c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page, City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of 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 60 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 collform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,OOOg pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.00c-rev.6116 Title 5 Official Inspection=orm:Subsurface Sewage Disposal System-Page 5 of 17 ZZ a5ed xeJ dH L9:2 860Z ti0 9aJ Commonwealth of Massachusetts Title 5 official Inspection Form 14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Narne information is required for every Hyannis MA 02601 2-1-18 per. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? r ❑ ® 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 NIA) ® ❑ 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 JSAS)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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 16.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.We Titles official Inspection Form:Suosurface Sewage Disposal System-Page6 of 17 £Z a5ed xed dH L9:2 860Z t70 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owners Name information is required for every Hyannis MA 02601 2-1-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1600 Gal Tank D Box and five chamber's: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Com more Will ndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 C M R 15.203): Gallons per day(gpd) Basis of design flow(seatstpersonslsq.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: 15ine.doc-rev.8116 Title 5 Official Inspection=orm:Subsurface Sewage Disposal System-Pop 7 of 17 r t7E a5ed xe� dH L9:2 860E b0 9aJ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments vvy 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is Hyannis MA 02601 2-1-18 required for every y page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution ibox, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativelAfternative 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 sys'tem by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.doc-ray.W6 Title 5 Official Inspeetien Form:subsurface sewage Disposal system-Page B of 17 5Z a6ed xed dH 856E 860E b0 9ad c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner owner's Name information is required for every Hyannis MA 02601 2-1-18 page. City/rows State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 2006 Permit # 2006- 108. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ®cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"cast iron and 4" PVC SCH -40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gal. Precast H-10 Dimensions: lot Sludge depth: t5ins.dcc-rev.6116 Title 5 Dfficial Inspectior Form:Subsurface Sewage Disposal System-Page 9 of 17 gZ a5ed xed dH 89:2 860Z tb0 gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of,outlet tee or baffle 2911 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle S Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at workink level. Tank and covers at 1' below grade. Inlet baffte,outlet tee. No sign of leakage or over loading. 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 15ins.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 LZ a5ed xed dH 89:2 260Z b0 qad Commonwealth of Massachusetts � i t 1 Inspection For T t e 5 Official m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 pa". Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc ray.06 TO 5 Olfidal inspection form:Subsurface Sewage Disposal System-Page 11 of 17 8Z a5ed xed dH 69:2 81.02 b0 98d I Commonwealth of Massachusetts Title 5 Official Inspection Form lili Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis annis MA 02501 2-1-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-27" below grade w/cover at 1'. Box is clean and solid w/one line out. No sign of over loading or solid carry over, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins.doc-rev.61IS TIUe S Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 62 abed xed dH 69:6E 860E b0 4ad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 203 Fawcett Lane `J Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. CRy/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is five infiltrators. Ck D Box;and camera out. No sign of over loading. 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 Mns.doc•rev.6!t 6 T tle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 OE a6ed xed dH 69:2 860E t0 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is Hyannis MA 02601 2-1-18 required for every ci !Town page. tY State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lne.doe•rev.e116 Tide S Official Inspection Fomr.Subsurface Sewage Disposal System•Page 14 of 17 l.E a5ed xed dH OOZE 8602 b0 9ad I Commonwealth of Massachusetts P Title 5 Official Inspection Form no Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VY 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view cf 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 slick t� /A u thins.doe•rev.E116 Title 5 Olfidal Inspection Forth:Subsurface sewage Disposal System-Page 15 of 17 Z� a6ed xed dH 00ZZ MZ b0 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v P 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope I ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water. feet -6 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: 1-23-06 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: T.H. on Design plan 1-23-06 11'-6" 11'-6" no G.K. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.611E Trle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ££ abed xed dH OOZE 860E ti0 4ad Commonwealth of Massachusetts Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 203 Fawcett Lane Property Address Fermanda Torres Owner Owner's Name information is required for every Hyannis MA 02601 2-1-18 page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B,C, D, or E'checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc rev.6116 Title 5 Official Inspedior Form:SubsurfKa Sexage Disposal System•Page 17 of 17 t,C abed xed dH 00:ZZ 860Z V0 9ad YOU WISH TO OPEN A BUSINESS? For Your Information: -Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME.in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures oh this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: 1 / Fill in please: + + r APPLICANT'S YOUR NAME/S: M' Z16t A• - r BUSINESS YOUR HOME ADDRESS? . �.3 Lust -t%t- 4/y,' :a. n rv.^d AA e: O�� �( TELEPHONE # Home Telephone Number NAME OF CORPORATION. ` . <3 Q).A y C/E Yu;Yl NAME OFNEWV_BUSINESS. TYPE:OF BUSINESS ;Z�7 IS THIS A HOME OCCUPATION?. YES . ` NO 7�_ ADDRESS OF BUSINESS_�,Q 3 Q T;Zni-. 't CA6ti'1 MAP/PARCEL NUMBER . [Assessing). When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM I SI ER'S OF E This individu I h e infor, e o an er ity a uirements that pertain to this type of bl�UWs.COMPLY WITH HOME OCCUPATION / RULES AND REGULATIONS. FAILURE TO Au prized a u e COMPLY MAY RESULT IN FINES, COMMENTS: U J 2. BOARD OF H ALTH MUST COMPLY WI IN ALL This individual ha bee f the permit requirements that pertain to this type of business. U . jf'�'l" HAZARDOUS MATERIALS REGULATIONS Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date:9U I l�j I�1y TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 0 fl/415 Ckclu-,P � /� L�QrT I01\f BUSINESS LOCATION: INVENTORY MAILING ADDRESS: .2,Pb f-a'u1C j LTV TOTAL AMOUNT- TELEPHONE NUMBER: I -to S 775_91 $0 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: L'/eanYu c INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: P p Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND-HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes r � U��e, �✓t� CIiC'n7�' G/Carun Laundry soil &stain removers .¢ r (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appli t' Sign ture� Staff's Initials t :i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ''p 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every 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 A. General Information forms on the computer, use 1. Inspector: \� . only the tab key to move your DOUGLAS A BROWN U cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC. Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 'e°0D Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification zsl ZZE I certify that I have personally inspected the sewage disposal system at this address and that& information reported below is true, accurate and complete as of the time of the inspection. Tlel inspection was performed based on my training and experience in the proper function and maintenance of one sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1;4,340 0# Title 5(310 CMR 15.000). The system: 5 ® Passes ❑ Conditionally Passes ❑ Faiis s�•1 a-�r ❑ Needs Further Evaluation by the Local Approving Authority 10/1/13 4spesSignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. J t5ins•3/13 Title 5 Official llnj.p ion Form:Subsurface Sewage Disposal System•Page 1 of 17 V 4 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for°Voluntary Assessments 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION OBSERVATION WAS NOT FOUND ON S.A.S B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-`Not for Voluntary Assessments 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND :below (Explain ) ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments „ 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank,and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates.absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4,M 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1113 every page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® 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)] D. System Information 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 203 FAWCETT LN Property Address NOWAK Owner Owners Name . information is required for HYANNIS MA 02601 10/1/13 every page. Citylfown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A EXISTING 1000 GALLON TANK D-BOX AND 4 BEDROOM S.A.S Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: HOUSE HAS BEEN VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Sve,� 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy . ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. M ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: S.A.S INSTALLED IN 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 FAWCETT LN Property Address i NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet.and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): r "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is HYANNIS MA 02601 10/1/13 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): NO SIGNS OF LEAKAGE OR SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: OBSERVATION PORT WAS NOT FOUND t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Mt 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ Teaching pits number: 3050 ® leaching chambers number: INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of,ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a M , <. 203 FAWCETT LN _ Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 £IOZ/0£/01 I=basWL0IOLZ= ddtLuLdsL,-XeidstpyiW2utssassV/sn-uw-aigmsu uq•umol*AvAm//:duq Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 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: 9/2013Date ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Z Jo Z a&'d spmD jImg-sV 2utssassV £IOZ/0£/Oi i=bosWL0i0LZ�ddeu Ldsu•XLidsl piMuissossV/sn-uuz-aiq Isu uq•umol-Av m//:d pnu Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 203 FAWCETT LN Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/1/13 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Z 3o Z a&'d sp uD jImg-sV 5uissassV TOWN OF BARNSTABLE LO+ ATION 2/���/� ��`-f✓c%%J ��✓ SEWAGE #aZ � VILLAGE A� 2 0v ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NOAR-t-17' s SEPTIC TANK CAPACITY C X' t s /a 0 LEACHING FACILITY: (ty X A' 9 xC_�Z' NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: i Jc g/�4� 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 �. � � � '� 45 �} \. �j Nv � � � �' ` `� �, �` _ � �1 �.,., � ._ . °�� � � � � � � s� � �. � � a x � � � �i �' � � �o ., � �, �` ' � � «.. i, �. `� � � N Fee o. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r ZIpphratton for Bigog;af 6p5tem Conotruction Vertu Application for a Permit to Construct1� Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. y4_11 N,C/,, J Owner's Name,Address,and Tel.No. Assessor's Map/parcel d Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) e7� `7' O gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank / 7 n Type of S.A.S.JZ5_6 Description of Soil � r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and=not.to place the system in operation until a Certificate of Compliance has been issued by this oard of Health. 1 Si/gne' l Date 3 Application Approved b " Date Application Disapproved by: LIZ Date for the following reasons Permit N Date Issued f i N . � � ' . •€ � - Fee �& THEaCOMMb!'"EALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS71 Yes 0[ppYicatiou. for �kgponl 6p5tem Cow6truction Permit Application for a Permit to Constructs/)Repair(e) Upgrade O Abandon O Complete System ❑Individual Components Location Address or Lot No. f�(��,N�� _!n Owner's Name,Address,and Tel.No. Assessor's Map/parcel Q d Installer's Name,Address,and Tel.No. Designer's,Name,Address and Tel.No. Type of Building: / Dwelling No.of Bedrooms �/ Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) -Other Fixtures Design Flow(min.required) y `7� O gpd Design flow provided T gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank / �5- a h Type of S.A.S..395­61 ��i f v 5-5- Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: C Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and,not-to place the system in operation until a Certificate of Compliance has been issued by this oard of Health. f � Signe Date 3X., r Application Approved by r � ® iJ/` Date Application Disapproved by: _Z ��L v Date A A fbri the following reasons Permit No. (� Q� Date Issued I ! /7 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 f/r % e-11,Z) at 3 ;:S7 ee_- has e n constructted in-accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. U m t /i _ dated Installer / Designer 0,�i v,-2 G2. #bedrooms Approved design flow gpd The issuance of this permit shall no be con trued as a guarantee that the system will functio as e r n Date y Inspector -------------------------------- 0. �Z/, Fee/ C� - - THE COMMONWEALTH Ors IMIASSACHUSE,i i S - _ . _ n PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 00 1=i!6pogat:i�pgtem Cow5tructiou Permit Permission is hereby granted to Construct ( - ) Repair ( ) Upgrade ( ) Abandon ( ) System located at ; d 3 U-" c r G-,�✓ �� ✓ 1-/,4 7- -,� /9 2 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction m st be 6mpleted within three years of the date of thi ,e it. r !1 Date Approved by Assessing As-Built Cards Page 1 of 2 J TOWN OF BARNSTABLE LOCATION 2 a-3 r4wc%,t ZIV SEWAGE 8,2w., /o VILLAGE /7'Y Aq- :S ASSESSOR'S MAP&LOTa7d 7 INSTALLER'S NAME&PHONE NOf)X--H K-1 r 3 0.7 i 1 t I JC SEPTIC TANK CAPACITY t x•s 4 a 0 U LEACHING FACILITY: (typed Al:, (size) 1� NO.OF BEDROOMS BUILDER OR OWNER /�t f/�T /'i�0-LT 6 PERMrrDATE: �,7j!:� 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 r 3 la C /4G% e ter Dale X 66,z ai,6 /� ~rJ•s http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=270107&seq=1 10/30/2013 Town of Barnstable °�:��E T Regulatory Services * Thomas F.Geiler,Director )Public Health Division rfip 'a Thomas McKean,Director 200 fain Street,Hyannis,lWIA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: D Installer: Address: . L `61 SOX a I Address: a S/ � vd w Ilh4 On was issued a permit to install a (dat (installer) septic system at �7 FPIWGC TT based on a design drawn by (address) WLW -,d (designer) 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- / I certify that the septic system referenced above was installed with major changes (i;e, , greater than 1;0' lateral relocation of the SAS or any vertical relocation of any component of the.septic system)but in accordance with State&Local Re . ations. Plan revision or 7 certified as-built by desi er to follow. A O F 4ft, DARRE V �di staller's S' atur 6, � 0 �G1 STS�� 61 \ SIN/7-AR`NN:: (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COA LIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CART)ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH`DIVISI4I�T. THANK YOU. Q:Health/Septic/Designer Certification Form "4 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I,1) WAA4eAtl' ,hereby certify that the engineered plan signed by me dated OZ•2-q-0 ,concerning the property located at 2�3 Fer-✓Cec LA-N L meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 42 . B) G.W. Elevation Z3.0+adjustment for high G.W. _ A1f 4 l� �/vU DIFFERENCE BETWEEN A and B N�A w�w 15 SIGNED I DATE: Oi ' "06 NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc _ TOWN OF BARNSTABLE LOCATION ' t��?w ,r "�;°' SEWAGE # VILLAGE ' /�y ::} -w t ASSESSOR'S MAP & 1,0172- 0 i c : INSTALLER'S NAME&PHONE NO/)P,'f.' '-` SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO.OF,BEDROOMS BUILDER OR OWNER PERMITDATE: _3 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 Pic l -:ors$tom• /.� _ ) v - ASSESSORS MAP Tj TEST HOLE LOGS NOTES: a �� MARYPARCEL : j 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH ti GEt THIS PLAN, 1995 MASSACHUSETTS TITLE' V & TOWN OF 5 � S01 L EVALUATOR :�:. �2H� R•`�- C�T i .-FLOOD ZONE : Q�ON F��}k(ZiU �`-� `?TA'8�. BOARD OF HEALTH REGULATIONS. ER y U WITNESS : } a gip REFERENCE : �',� DATE : t/AjqwZfO 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, ►R ' �'� PERCOLATION RA E :CLASS � 50(Goa ✓,TAR=0,�K 6 2-MIN[I G'N N SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO l CON � INSTALLATION. a Pd I o � ER MT •e �� � '. TH- I p 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE h" skv A (.DPrM`1 ID A� DETERMINATION.: IOYR / � `� f q o a 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS cettSPECIFIED OTHERWISE) RE ` 1(44J4, - �, loy � --�` �t �, `'�' q 5 .THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A LOCATION MAP O•r r- S LIEN vu z ; E G GARBAGE DISPOSAL. M13 No. 1140 �7f U1�1 37 -, '��.: � ,.,.,,` � C 2 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C C `v ( " � C /I(( MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON a1 �NITARlh 6 7 - --•`t ,�� A BASE OF 6"OF CRUSHED STONE. ^ _ o / E 4 TIN oot , ... f u✓ I C/� US1 o IN e65642-vU Sp SEPT I C "ISYSTEM DES I GN j off- FLOW ESTIMATE tJ BEDROOMS AT 110 GAL/DAY/BEDROOM - q4O GAL/DAY / "-.- SEPTIC T<NK ExI`aT GAL/DAY x 2 DAYS GAL \, cr✓ sP L ktllyc ' eNpTt 7) USE 1 GALLON SEPTIC TANK-14EL ) SOIL ABS(RPTION •SYSTEM �\ 1r4PIzTP-hTo9, !�;oSU UN/T-5 vv/ yiI OFST S I D AREA:[(��c ')2 + ( tc�) k Z. x 0 L IV V BOTFOM AREA: 4dx 1CK 6.7Y� Be / --' > I/vo G Pry W ?�� �r -- --` i SEPTIC ;SYSTEM SECTION r gg '4, 0. 47-� ' . V N & b� 4 I h ✓ale�r Q A*� (J E ( Lf o `/ :�� (� If 9-0 ,-tome t3flie D-BOX GAL ,70 1 , SEPTIC TANK 14V,04,e-,�S) 11 11 - SITE AND SEWAGE PLAN LOCAT I ON Z&3 F,-4-WCerThill Lw� ISM goof 1E `— 3��, 35,a f PREPARED FOR : WAS lie IZv SCALE : j DARREN M. MEYER, R.S. IL w - s o P.O. BOX 981 DATE : oz-2w -66 EAST SANDWICH, MA 02537 w 1L1�c92. DATE HEALTH AGENT Ph: 508 362-2922 W Z