HomeMy WebLinkAbout0022 FIRST AVENUE (HYANNIS) - Health 22 FIRST AVE., HYANNISPORT
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Commonwealth of Massachusetts
Title 5 Official Inspection Form F�
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments{
22 First Avenue r i
Property Address
Richard &Jeanne Egan a
Owner Owner's Name
information is required for every West Hyannisport Ma 02672 7/13/2019
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not,be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information S4-fr 39 S!o
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
774-2484850 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
7/13/2019
Inspector'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 a
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
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
page. Cityfrown 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 22 First Ave West Hyannisport is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 2 perforated pipe leach trenches with Cultec 330's.
The system was found to be in proper working condition at the time of inspection.
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):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West HY P annis ort Ma 02672 7/13/2019
page. Cityrrown 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 obstructedpipe(s). The
Y 4 P P 9 Y
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:
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
{
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is p
required for every y West H annis ort Ma 02672 7/13/2019
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
' system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
I
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
; 10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
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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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
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)]
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1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
{
I
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
Description:
Number of current residents: 1
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
Last date of occupancy: current
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
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
I 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:
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
22 First Avenue
Property Address
I
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
(page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
i
❑ Single cesspool
❑ Overflow cesspool
I
I ❑ 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
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❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 1998
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Were sewage odors detected when arriving at the site? ❑ Yes ® No
j 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
I Comments (on condition of joints, venting, evidence of leakage, etc.):
{ Joints in good condition, no leakage, vented through roof.
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is West H annis ort Ma 02672 7/13/2019
required for every Y P
page. Cityrrown 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:
1500 gallons
Sludge depth:
3"
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.
l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
II
i
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
'information is p
required for every y West H annis ort Ma 02672 7/13/2019
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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c "Commonwealth of Massachusetts
Title 5 Official Inspection Form
,e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hyannisport Ma 02672 7/13/2019
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
0"
t 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.
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I
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is West H annis ort Ma 02672 7/13/2019
required for every Y p
page. City/Town 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:
1
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ - innovative/alternative system
Type/name of technology:
I t5insp.doc•rev.7/2 612 0 1 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hy p annis ort Ma 02672 7/13/2019
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 perforated pipe leach trenches with Cultec 330's. Both lines were video inspected
and found dry with no signs of past overloading. One trench is 12' and the other is 20'
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.):
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j
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
0
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hyannisport Ma 02672 7/13/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
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i
l
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is p
required for every y West H annis ort Ma 02672 7/13/2019
page. City/Town 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
2 �
A2. 32
Aq - 55,
(3N: SS 6
AS % Y6
3y'i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is required for every West Hyannisport Ma 02672 7/13/2019
page. Cityrrown 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: 1 feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
r ❑ 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.
i
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
1
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 First Avenue
Property Address
Richard &Jeanne Egan
Owner Owner's Name
information is p
required for every y West H annis ort Ma 02672 7/13/2019
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Pay To:
Banner Environmental Services, Inc Invoice
16 Back River Way
Duxbury MA 02332 Date Invoice#
Tel: 781-934-6873 3/16/2009 09-58
Fax:866-816-2374
Bill To:
Richard Egan
PO BOX 691
Osterville MA 02655
P.O. No. Terms Due Date
Due on receipt 3/16/2009
Item Description Qty Rate Amount
Asbestos Abatement Asbestos Abatement: Residence, 22 First Ave.,West Hyannisport, 920.00 920.00
MA 02762
-Removal and disposal of—30 LF of asbestos containing pipe and
j fitting insulation
•HEPA vacuum all surfaces to remove suspect asbestos debris
Air Clearance Air Clearance Sampling 250.00 250.00
I
Total $1,170.00
I
Payments/Credits $-585.00
Please write invoice number on check Balance Due $585.00
,ROT ENVIR®TEST LABORATORY, Inc. _
307 Pond Street Westwood,MA 02090 T:781-278-0080 F:781-278-0090 www.etestlab.com
b0cvxoa
Banner Environmental Services,Inc.
16 Back River Way
Duxbury ,, NIA 02332
Attn: Mr.. Rudy Nelson
Subject: Asbestos Air Testing:
22 —lsr Ave.
Hyannis,MA
Project 9: 42822
To Whom This May Concern,
Please find enclosed the air results taken on March 11,2009. Envirotest,was contracted to perform.
sampling for airborne fibers at the address cited above. All Samples collected, were analyzed by
Envirotest Laboratory for the determination of an airborne fiber count. The analysis was performed in
accordance with 'Phase Contrast Microscopy NIOSH Method 7400."
Envirotest Laboratory is accredited under the Proficiency Analytical Testing Program for air analysis
by Phase Contrast Microscopy. Envirotest Laboratory is also certified by the State of Massachusetts for
analytical Services.
If you have any questions concerning your results,this report or the analytical methods employed,
please feel free to call me at(781)278-0080.
Sincerely,
Samuel N. Cohen
Industrial Hygienist
enc.
Envirotest Laboratory Is Accredited By The Proficiency Analytical Testing Program(AIHA)
f
0
ENVIR®TEST LABORATORY, Inc.
Mao0 3071lond Street Westwood, MA 02090 T:781-278-0080 F:781.-278-0090 www.etestlab.com
SAMPLED BY: SMITH
ANALYZED BY:SMTLhI Project 9: 42822
LAB SAMPLE SAMPLE SAMPLE START STOP TOTAL FLOW VOLUME RESULTS
NUMBER DATE TYPE LOCATION TIME TIME TIME RATE FIBER/CC
J /XXXX J / xxxx
BLANK-2 SAME BLANK-2 :BLANK SAMPLE 2 XXXX XXXXX XXXX XXXX XXXX 0
BASEMENT(FIL CONTAN.)
BAY-1 SAME PC:M NEXT TO HEPA 1:05 2:25 80 15.0/15.0 1200 .004
EPA RECOMMENDED RELEASE CRITERION OF 0.01 FIBERS/CUBIC CENTIMETER
OSHA PERMISSIBLE EXPOSURE LIMIT OF 0.1 FIBERS/CUBIC CENTIMETER.
CONTRACTOR: BANNER
FORM30 C&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOWN
z W DEP L41A
NT
ADDRESS /// /�/y�
GSM Sv6 y`0� ` og L
Z- / �✓-%y
2 2 PA&C-1 k-- TELEPHONE
Address W , %" l A-4 K i S U to �-4 Occupant �2 v PA S^yn 0 K C
Floor -- Apartment o. No.of Occupants
No.of Habitable Rooms 15 No.Sleeping Rooms 'Z
No. dwelling or rooming units No.Stories
Name and address of owner___14!ACtL- J9
Sc) J:_ \�2L5"( A,.`E �Aj 44 Remarks Reg. Vio.
YARD Out Bld s.: Fence :
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress: and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness: L43 91 eSS
Stairs: L.4:o o,-j 10 1 17sL a 453
Lighting: tA to S. -t o E_
STRUCTURE INT. Hall,Stairway: 0"A,-'V_ _ h, lr'C¢Aj%co
Obst'n.: rLaG�Co�-
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
r Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other.-
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES O ERJU "
INSPECTOR �•S • TITLE 1 ¢'Co R-
AM: �L'
DATE ZO® TIME 1 00
A.M.
THE NEXT SCHEDULED REINSPECTION �` P.M.
410.750: Conditions Deemed.to Endanger or Impair Health or Safety
The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human.habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
tt+e r°k
Town of Barnstable Barnstable
f�"V, �o
AN-ftmica City
(r � yI' Regulatory Services Department
t BARS STABLE. 1
"3s Public Health Division
TFD MAI A' 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 ThomasF.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 7007 3020 0001 3429 8912
January 7, 2009
Richard and Jeanne Egan
P.O.Box 691
Osterville, MA 02655 _
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 22 First Ave. West Hyannisport, was inspected
on January 7, 2009 by Jaime Cabot, R. S. , Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the state sanitary code were observed:
105 CMR 410.482- Smoke Detectors and Carbon Monoxide Alarms:
No smoke Detector provided for the basement.
105 CMR 410.3537 Asbestos:
Corrugated Asbestos pipe insulation was observed in a defective condition on heating
system pipes in the basement.
105CMR 410.500- Owners Responsibility to Maintain Structural Elements:
Peeling paint was observed on the bathroom ceiling.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing a Smoke Detector in the.basement.
You are directed to begin corrections of the Asbestos violation listed above within
seven (7) days of your receipt of this order by beginning the necessary repairs or
contract in writing with a third party,within five(5) days, to correct the Asbestos
material violation in accordance with the regulations of the Department of
' - - -
Environmental Protection appearing at 310 CMR 7.00 and in accordance with the
regulations of the Department of Labor and Workforce Development.appearing at
453 CMR 6.00.
You are directed to correct the violations listed above within thirty (30) days of this
order by repairing the peeling paint on the bathroom ceiling.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division an sk to speak with the inspector who performed the inspection.
PER ORD OF TH BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town.of Barnstable
Cc: Jaime Cabot, R.S., Health Inspector
y
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p
a
F
1 ,
r � w
�FTHE Tp�\
Town of Barnstable Barnstable
A&-ftmica CRY
sw Regulatory Services Department s
BARNSTABLE.; �
N1 ASS.
Public Health Division
200 Main Street, Hyannis MA 02601
011ice: 508-862-4644 ^ t Thomas F.Gcilcr,Director
FAX: SOS-7)0-G30'1
�p: —J Thomas A.McKean,CI-10
� �
lttC.r �q�►'7
V CERTIFIED MAIL 7007 3020 0001 3429 8912
L January 7, 2009
Richard and Jeanne Egan
P.O. Box 691 r
Osterville, MA 02655 t
NOTICE TO ABATE VIOLATIONS OF 105 CMR.410.000, STATE SANITARY
CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 1.70.
The property owned by you located•at'22 First Ave. West Hyannisport, was inspected
on January 7, 2009 by Jai iiie Cabot, R. S. Healfli'Inspector for the Town of Barnstable.
rs�
This inspection was�cond-i>'rcted`6n-the brasis°of the racntal,iegistration in accordance with
Chapter'170'of the Town of Bar'n5ta�le C0 e
The following-violations of the:state sanitary code were observed:
105 CMR 410.482- Smoke Detectors and Carbon Monoxide Alarms: in a-''`/ems I:v
No smoke Detector provided for the basement. •'4
' 3Ce Qr 7,$4aC�l
105 CM R 410.353- Asbestos:
Corrugated Asbestos pipe insulation was observed in a defective condition on heating
system pipes in the basement:. Q// :�Sv/aio.? re wra
/ol0 9
105CMR 410.500- Owners Responsibility to Maintain Structural Elements:
Peeling paint was observed on the bathroom ceiling. -er.,,tar if /-�,,wsAretO
to .•.Pc►i�f �-�? � bed�oo...-� and �t��iod�d 63�
You are directed,to correct the violations listed a ove within.hventy-four,(24) hours
of your receipt of this notice by installing a Smoke Detector in the basement.
You are'dir ected to legin'correctio'ns of ltlie Asbestos violation listed above within
seven 7 'd'a ys ot" our'r'ecei `t of this'o►!Wb '66 in�ina'ttie`iiecessar ►=e airs of
( )^ Y Y p J g , b Y p
contract in-writing with.a,thir'd party witliin4tive'(5)days, 'to correct the Asbesto's
material violation in accordance with the regulations of the Department of
t
Environmental Protection appearing at 310 CMR 7.00 and in accordance with the
regulations of the Department of Labor and Workforce Development appearing at
453 CMR 6.00.
a
You are directed to correct the violations listed above within.thirty (30) days of this
order by repairing the peeling paint on the bathroom ceiling.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and, sklto speak with the inspector who performed the inspection.
PER ORD OF TH BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Jaime Cabot, R.S., Health Inspector
i
i
..r
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date % Time: in 10,* 00 Out
Owner Tenant 0\, - 1A 0(z-5—
Address Address
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
E, L
4. Water Supply R-
5. Hot Water Facilities
2;
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
�3 o
12. Exits
1 0' G NA 12 LA 10 1, FoZ
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
T; t-,j k L C
15. Garbage and Rubbish Storage and DisI56sal A,
16. Sewage Disposal
17. Temporary Housing ?,JN
18. Driveway Width
19. Number of Tenants Observed
PART 11
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max) ' ,
Person(s) Interviewed Y Inspector
If Public Building such as Store or Hotel/Motel specify here
'TOWN OF BARNSTABLE ,
LOCATION a oZ. I I S I 1)tl e SEWAGE # P�� Ll
VILLAGE i'P ! I O ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. E
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Cy/7eC.-3�®� (size) 3 v fd/rX y
NO:OF BEDROOMS 02
BUILDER OR OWNER Rt c~ rGAyt
PERMIT DATE: )F�°'"1�C�3 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
i
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for ]k5po!9al *pgtem Comaructton 3permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a12 r>%?S j 1� G_ Owner's Name,Address and Tel.No. 777E^ -�!361
NyAnnu�o>—�" T e�f fz�3�l
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C)s ec,���
Type of Building:
Dwelling No.of Bedrooms >91 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) * 14OC%U /SQD t�'A/• Tn ?J/1%h ��(
-C-fTeC 330 s sv ,.Qm s18 's-03exc.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of a
Signed' Date Awe �,6
Application Approved by ot Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. $_ Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. V
y PUBLIC HEALTH DIVISION - TOWN—OF BARNSTABLE, MASSACHUSETTS Yes
R,wIftation for Oigozaf *pgtem Cowaruction Permit
plication for a Permit w Construct( )Repair(41`rupgrade( )Abandon( ) El Complete System ❑Individual Components
%G'S j� c_ Owner's Name,Address and Tel.No.
Location Address or Lot No. �'a 77B y3 �j
Assessor's Map/Parcel 1Rfi,20jo / r ,I ESA'f
6 0?a /'Lei F AVr
'Installer's Name,Address,and Tel.No. Lj,d6 "sa S Designer's Name,Address and Tel.No.
�a-C-c0,..�1Cr
Type of Building:
Dwelling No.of Bedrooms :Q Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil '
Nature of Repairs or Alterations(Answer when a plicable) 7-0 / 0 0
1/ - r
t�
�S � ,1�
-1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of a
Signed % + Date r'
Application Approved by 7 / Date
Application Disapproved for the following reasons v
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
' Certificate of Comptiance
THIS IS TO CERTIFY,that the�On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(�)'
Abandoned( )by ._ c r c 111-r rc.1/j7?
at 2 7 j It,J has ben constructed in accordance
y with the provisions of Title 5 and the for disposal System Construction Permit No. dated
Installer �F )'/c cc.d')/,j Designer f
The issuance of this permit shall not beconstrr ed as a guarantee that the system will feu-n-c-tiion as designed.
Date -' 1 ` 9 :>'' Inspector
Q
— ————————— ———————————————————Feed
No. qz�m
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
'izpooal 6pgteut cow6truction Permit
Permission is hereby granted to Construct( )Repair(;/)Upgrade( )Abandon( )
System located at _;
i
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. ;:
i
Provided: Construction must be ompl ted within three years of the date of this P'e'I.
Date: - � Approved by
. NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CC
RTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify*that the application for disposal works
construction permit signed by me dated !PA
concerning the
located at /-v XAnrl�r�a��' ` meets all of the
property
following criteria:
e There are no wetlands located within 100 feet of the proposed leaching facility
e There are no private wells within 150 feet of the proposed septic system
e There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
e If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A Top of Ground Elevation(according to the Engineering Division G.I.S.map) :
B)Observed Groundwater Table Elevation(according to Health Division well map) !a•6
SIGNED: DATE: �2V, ? / 9
LICENSE?SEPTIC SYSTE 4141
M INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system.Also tithe licensed Installer posesses a certified plot plan.
this plan should be submitted].
q:health folder:cent
0
J
„ O
C4
1
GJ
� c
r
r
TOWN OF SAHN8TA8LE
1 REPORT SUPPLEMENTARY/COM MATZON 8EPOUT
NAME (LAST. FIRST. MIDDLEL./• • DIVISION 102"
NOSE DETAILS : OBSERVAT:CNS-;:EHIIE EVIDENCE. SIAIAL I
RegA } c ,\rs n w,
. 1
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f K, n g
Vie, `t v�ceeto 4L,111121M ireS 1� ott `tk Cov-ne,,r c�
a CVCX. i t l-le- Be" �'+ S k a
(-n &A 0S nw e s
(P)4i le cn -T-J rvi on a4
OU
I
ran
,..1
.. v ri a �.::. ,��
This is an interdepartmental report. I
It is-a-summary and aces not
qc ss rily contain all the fact^ or I
information known tc the
I
!I �
I
SJBMI='D 3Y PAGE L
1 �
Health Complaints
28-Jul-00
Time: Date: 7/10/00 Complaint Number: 2436
Referred To: JEROME DUNNING Taken By: LS
Complaint Type: GENERAL
Article X Detail:
Business Name:
Number: Street: CORNER OF FIRST AVE. &
Village: W. HYANNISPORT Assessors Map_Parcel:
Complaint Description: BAD ODOR FROM CHICKENS, TURKEYS,
ROOSTERS, DOGS.
Actions Taken/Results: �v C 4,
.� u^- szficfi akc,
Investigation Date: Investigation Time:
1
v
TROY WILLIAMS
SEPTIC INSPECTIONS #,
Certified by MA Department of Environmental Protection (508) 760-1819
40 Old Bass River Road SFP
South Dennis,MA 02660
Commonwealth of Massachusetts e
Executive Office of Environmental Affairs 19
Department of
Environmental Protection
William F.Weld Trudy Coxe
Govertwr so-atary
Arpeo Paul Cellucci David B.Struhs
LL Governor ConvnW&kxwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION
Property Address: _,�a F i. S 7L Au L I Fi y ac,w, S�O Address of Owner.
Date of Inspection: (If different)
Name of Inspector.
/ oyy
Company Name,Address ad Telephone Number.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of 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:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector-'a Signature: /� J� Dote:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES: /V/19
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exAltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address a pZ Fl/5 4-
Owner. A, a L I S-, (-
Date of Inspection
yJa3 /94
BI SYSTEM CONDITIONALLY PASSES (continued) ^/
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obst acted 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
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IV 119
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:
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water 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.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -?a F)r S�' ✓L
Owner.
Date of Inspection:
3/ qC
D] SYSTEM FAILS: q/aN
I have determined that the system violates one or more of the following failure criteria as defined 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.
— 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 IN day flow.
Required pumping more than 4 tunes 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.
El LARGE SYSTEM FAILS: /1//4
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:
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 Il of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: q'o F.r 5
Date of Inspection: 'vl4 • L S y �" �'
q /as / 9 �
Check if the following have been done:
_Vl�mping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been
during that period. Large volumes of water have not.been introduced into the system recently or as part of this inspection.
)VI9 As built plans have been obtained and examined. Note if they are not available with N/A.
ZThe 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.
ZAll system components, excluding the Soil Absorption System, have been located on the site.
/J/IlThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffies 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 or
approximated by non-intrusive methods.
/The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2a F r s 4- c.
Owner. M C. S5 y a
Date of Inspection: 4 6
RESIDENTIAL- FLOW CONDITIONS
Design flOw:21±--gallons
Number of bedrooms:d
Number of current residents: d
Garbage grinder(yes or no):_&O
Laundry connected to system(yes or no): Y�S
Seasonal use(yes or no)://o
Water meter readings, if available: W 4-4r
Last date of occuparicy:_.jt�s-b x. g /.2 2
COMMERCIAL/INDUSTRIAL: /\11,9
Type of establishment:
Design 1l0w:_Zal1ons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
ti�'I7t✓ �,.. fin ( TTi h c�,/ ' C f.� /�ar4 S Trc. ^�'�h Gs��- /� /A•. �.
System Pumped as Part of inspection: (yes or no) NV
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
Septic tankldistribution box/soil absorption system
ZSingle cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 0r, 4
Sewage odors detected when arriving at the site: (yes or no). No
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address: OC a F;r S+ Al G
Owner. S w o, C-
Date of Inspection: /23/f
SEPTIC TANI:11//,9
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain) `
Dimensions:
Sludge depth:
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:
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.)
GREASE TRAP:/ eg
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(e:plain)
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:
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 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 02 Owner. Fir 5 ✓Owner. Z
Date of Inspection:
y/a3 /yG
TIGHT OR HOLDING TANK: V14
(locate on site plan)
Depth below grade:
Material of constriction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity: rallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_N/A
(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:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address` �?2 F'r s•- f}✓G
Owner. A 6-c T S B
Date of Inspection: / /,2 3 J5`
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible;excavation not required, but may e b approximated PP d by non-intrusive methods)
It not determined � ptobe ezplaip:
�- 4
11 '� ✓ r. .A JS J . JII.� Gr
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration: G o t MCA ; a L
Depth-top of liquid to inlet invert:_ S/ j—
Depth of solids layer. /\/a 7
Depth of scum layer: A/o/V E
Dimensions of cesspool:_ _c- ' A.e r i l k- S-
Materials of construction: G'r-S S 4",, o ( b/a c./t- .
Indication of groundwater: A/d/V'c-'
inflow(cesspool must be pumped as part of inspection) C y S.S 4:7 CA n�e p t1
/h S ✓J� ��01.. �
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cc w r In
J
1 SO S O#, G
4-.l�'r` �. i r3 /o a s o Y ru.. a C �a 7/c i�nt fyti�., 'J s�.
le c/� ' a, f dF ti` S /Vz, W4�-/� �r. ry �eS � / gwore o/
PRIVY:�[�,q
(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 11/03/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
9 /a3 / qc
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
� Cis Sao 00 � •
DEPTH TO GROUNDWATER
Depth to groundwater: -- feet adjusted high groundwater level
method of determination or approximation: / ,„ A 99 , L e r C, d , / /o w 6 0 41-V C. •�
BLS s ,FJo o cam' 41 N O b•i— e_- 7'Q I/ k, -
9
i