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0013 FOURTH AVENUE (HYANNIS) - Health
13 ,FOURTH AVE. - ; Y HYANNIS A 246 185 . o a 0o a TOWN OF BARNSTABLE LOCATION '� I DJ 9Mk SEWAGE # Z,00/- z/S- VILLAGE PD ASSESSOR'S MAP & LOT Z*' S'-E INSTALLER'S NAME&PHONE NO. j SEPTIC TANK CAPACITY SCTb 5'e 0T1L- LEACHING FACILITY: (type) -30 SOS.7N,-t L, (size) NO.OF BEDROOMS s� BUILDER OR OWNER 8&J101:(25oN PERMITDATE: COMPLIANCE DATE: r/-7/oi 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:M3 , Oal 0 O Z O s _ 0 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 13 Fourth Avenue m Property Address William and Carla Senst Owner Owner's Name information is required for every West Hyannisport MA 02672 2/24/2016 page. City/Town State Zip Code Date of Inspection co Lq Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information p on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 Cityrrown State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/24/2016 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. : , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ow VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 page. City/Town 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: ® 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 observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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 wM 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is West H annis required for every Y port MA 02672 2/24/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name required for is every West H annis required for eve Y port MA 02672 2/24/2016 page. City/Town 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 welt`*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow 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 M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is West Hyannis port MA 02672 2/24/2016 required for every p 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 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 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 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name on isrequired for every West H annis Ort MA 02672 2/24/2016 page. 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? 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. I ® ❑ 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): 3 Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West HY p annis ort MA 02672 2/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: 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 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2015; 21,000 gallons and 2014; 18,750 gallons 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health 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. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information fo is every West H annis required for eve Y port MA 02672 2/24/2016 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: Compliance issued 5/07/2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 23 inchesfeet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 13 inchesfeet 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 Typical Sludge depth: 0" 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 �M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 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 47" Scum thickness 1" I Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: i Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): i I 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•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 ;M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is West H annis ort MA 02672 2/24/2016 required for every y p 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 effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover. Utilized a camera to view the distribution box. 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.): I 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): ei If SAS not located, explain why: Leaching field without inspection port. l5ins•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 �M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West H Yannis port MA 02672 2/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-3050's ❑ leaching galleries number: i ❑ 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.): No inspection port located. probed soil and no standing effluent observed in probing. 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 page. City/Town 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.): i 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-3113 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 M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is West Hyannis port MA 02672 2/24/2016 required for every p 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 I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is West Hyannis port MA 02672 2/24/2016 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map i ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater Contour Map 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 13 Fourth Avenue Property Address William and Carla Senst Owner Owner's Name information is required for every West Hy p annis ort MA 02672 2/24/2016 page. City/Town 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 i a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 Y TOWN OF BARNSTABLE LOCATION ,,'1113.. r0 (�11�PAe_ SEWAGE N_�°/-L/S VILLAGE Jt^1 RQZT ASSESSOR'S MAP&LOT_L' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l sib Se gaNe 30SOS�N ,L` �t LEACHGFACILrTY:(type) (size)IN e�Tr, �X/J� YZt NO.OF BEDROOMS_ BUILDER OR OWNER 6&jnE f.So,\J PERMITDATE: `i-9 ( COMPLIANCE DATE: f/��o/ 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 16, 0 0 0 31 I 'D�s'r36,r A; Z „ , t yt' $3 S�trr of http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=246185&seq=1 2/24/2016 Print Page Page 1 of 3 Print this page 1 . Owner Information - Map/Block/Lot: 246 / 185/- Use Code: 1010 Owner Map/Block/Lot GIS MAR SENST, WILLIAM& CARLA 246/ 185/ Owner Name as of PO BOX 392 Property Address 1/1/15 WEST HYANNISPORT, MA. 13 FOURTH AVENUE (HYANNIS 02672 Co-Owner Name Village: Hyannis Town Sewer At Address: No GIS Zoning Value: RB . Assessed Values 2016- Map/Block/Lot: 246/ 185/- Use Code: 1010 2016 Appraised Value 2016 Assessed Value Past Comparisons Building $ 61,400 $ 61,400 Year Total Assessed Value: Value Extra $ 17,900 $ 17,900 2015 - $ 310,400 Features: 2014 - $ 310,500 2013 - $ 310,600 Outbuildings: $ 1,800 $ 1,800 2012 - $ 309,900 $ 240,400 $ 240,400 2011 - $ 316,300 Land Value: 2010 - $ 320,600 2009 - $ 334,300 2008 - $ 380,900 2016 Totals $ 321,500 $321,500 2007 - $ 408,400 o Tax Information 2016- Map/Block/Lot: 246/ 185/-Use Code: 1010 Taxes Hyannis FD Tax (Residential) $ 778.03 Community Preservation Act $ g9.80 Tax Town Tax(Residential) $ 2,993.17 Fiscal Year 2016 TAX RATES HERE $ 3,861 o Sales History - Map/Block/Lot: 246/ 185/-Use Code: 1010 History: Owner: Sale Date Book/Page: Sale Price: SENST, WILLIAM & CARLA 2007-07-06 22170/168 $392700 KUSIAK, KURT S & KATHLEEN J 2005-09-12 20249/120 $299900 http://www.townofbamstable.us/Assessing/printl6.asp?ap=0&searchparcel=246185 2/24/2016 Print Page Page 2 of 3 CLAUSSEN, FREDERIC P 2001-05-30 13883/314 $150000 KOSTKA, JOHN E & DEBORAH A 1996-08-23 10359/171 $1 KOSTKA, JOHN E & DEBORAH A 1994-04-15 9149/225 $24900 KOSTKA, JOHN E & DEBORAH 1987-07-22 5843/254 $117000 DORAN, MARK 1987-05-12 5716/52 $125000 DORAN, MARIE V 1987-01-29 5538/148 $110000 CUTTER, CINDY L 1987-01-15 5538/148 $110000 CUTTER, CINDY L 1986-05-23 5094/49 $98000 NICKULAS, LARRY D 1986-02-28 4944/112 $625000 TELLIER, EDWARD A &JUNE 1 1964-07-13 1260/581 $0 . Photos 246/ 185/-Use Code: 1010 .F, . Sketches - Map/Block/Lot: 246/ 185/-Use Code: 1010 } 'wo 1( As Built Cards:Click card#to view: Card #1 . Constructions Details- Map/Block/Lot: 246/ 185/- Use Code: 1010 Building Details Land Building value $ 61,400 Bedrooms 3 Bedrooms USE CODE 1010 Replacement Cost $94,430 Bathrooms 1 Full-0 Half Lot Size (Acres) 0.18 Model Residential Total Rooms 4 Rooms Appraised Value $ 240, http://www.townofbamstable.us/Assessing/printl6.asp?ap=0&searchparcel=246185 2/24/2016 r Print Page Page 3 of 3 Style Ranch Heat Fuel Gas Assessed Value $ 240 Grade Average Heat Type Hot Air Year Built 1950 AC Type None Effective depreciation 35 Interior Floors Hardwood Stories 1 Story Interior Walls Drywall I Living Area sq/ft 870 Exterior Walls Wood Shingle Gross Area sq/ft 1,780 Roof Structure Gable/Hip Roof Cover Asph/F GIs/Cmp . Outbuildings & Extra Features- Map/Block/Lot: 246/ 185/- Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value BMT Basement-Unfinished 750 $ 15,000 $ 15,000 FPL 1 Fireplace 1 story 1 $ 2,900 $ 2,900 WDCK Wood Decking 160 $ 1,800 $ 1,800 w/railings . Sketch Legend Property Sketch Legend B2N Barn-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only BAS First Floor, Living Area FTS Third Story Living Area(Finished) SOL Solarium BMT Basement Area(Unfinished) FUS Second Story Living Area(Finished) SPE Pool Enclosure BRN Barn GAR Garage TQS Three Quarters Story(Finish( CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished) FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished) FCP Carport KEN Kennel UTQ Three Quarters Story(Unfini: FEP Enclosed Porch MZ1 Mezzanine, Unfinished UUA Unfinished Utility Attic FHS Half Story(Finished) PRG Pergola UUS Full Upper 2nd Story(Unfinis; FOP Open or Screened in Porch PRT Portico WDK Wood Deck PTO Patio Microsoft VBScript runtime error'800a01a8' Object required: " /Assessing/print16.asp, line 151 http://www.townofbamstable.us/Assessing/printl6.asp?ap=0&searchparcel=246185 2/24/2016 No. a17 J'� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ✓ 01pplication for, Migogal *pgtem Cortgtrurtioti Permit Application for a Permit to Construct( )Repair( C41u1pgrade( )Abandon( ) WompleteSystem ❑Individual Components Location Address or Lot No. .1 cs� /_y, Owner's Name,Address and Tel.No. Assessor's Map/Parcel D ids�"" �'� 2W _l � 17 e,Address,an I No. Designer's Name,Address and Tel.No. 1 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 � &0 gallons per day. Calculated daily flow ���i gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank S-e Type of S.A.S. % Description of Soil Nature of Repairs or Alterations(Answer when applicable) ct.�'�tRS-� N 1� CQk 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 be Board of Signed Date —6L Application Approved by Date Application Disapproved for the following reasons Permit No. �idy 2L.1� Date Issued —'�� .. -. . ti- �..�;.w. .. ... _. ... r;A a.' .. ..:..f.•-•.--..4�4,.c:., No. � - =Z.►a: .�,,. .. - Fee •_� _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ✓' Application for'330;pozal *pitem Congaruction Permit Application for a Permit to Construct( )Repair( 'Upgrade( )Abandon( ). Womplete System ❑Individual Components Location Address or Lot No. v Owner's Name,Address and Tel.No. c� Assessor's Map/ParcelO� s A, 2qv - Install N e,Address,and I. o. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 7�2 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures -w•� Design Flow ;z>y gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets %r Revision Date '. Title / C�,:f 7 t - Size of Septic Tank' 7. 1�9iP 1 Type of S.A.S. At C jer Description of Soil .e Nature of Repairs or Alterations(Answer when applicable) Tet:bTd4�\ � CAD SVO-) i C_`1 0,44.. is a Date last inspected: r 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 beet`.,,dt 'ssuedby this Board of Heal".. Signed Date Application Approved by .-- Date Application Disapproved for the following reasons Permit No. �_,0 - 2! 1'� �; Date Issued y — —d/ f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance A THIS IS TO CER -•>> • atiathe On-site Sew t�tsposal System Constructed( •j)Repaired( )Upgraded Abandoned( )by at l S "r"l- has been constructed in accordance with the provisions of Title 5 and the for Disposal�System Construction Permit No. _,VW/ Z/Sdated y- j�—Q Installer Designer The'issuance of this permitphall not be construed as a guarantee that the system ll f eti s designed n Date O/ Inspector__/ ----------------------------------------.._ . ... ... No. 2-1 S' -.. . ''Z q G. Fee f��— THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Iigpogar 6potem Cow5truction Permit Permission is hereby granted to Construct( )Repair( L14grade( )Abandon( ) System located at �..� u and as described inthe above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must he copleted within three years of the date of thist. Date: �/ "r Approved by r i 1/6/99 NOTICE: This Form Is To Be,ITsed For the Repair Of Failed Septic Systems Only. ' CERTIFICATION OESKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERTMIT (WITHOUT DESIGNED PLANS) here ce rtify that the application for disposal works construction permit signed by me dated -dg`� , concerning the propertylocated at � �0 meets all of the following criteria: K This failed system is connected o i y d to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. (There are no wetlands within 100 feet of the proposed septic system ll There are no private wells within 150 feet of the proposed septic system (Ther• e 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 not be located less than five feet above the maximum a justed groundwater table elevation..[Adjust the groundwater table using the Frimptor method when pplicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(ld) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment . DIFFERENCE BETWEEN A and B SIGNED : DATE: L _b [Please Sketch pr posed plan of ,stem on back]. i`10TICG Based upon the above information, a repair permit xill be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert � �© � r_ l Vv r Q�� 1'' ��•. .�. • _ � • /� 7- TOWN OFBAMSTABLE LOCATION SEWAGE'#' ^�,60/- Z'-1S- 't'- VILLAGE ASSESSOR'S MAP & LOT Z qc-1;?5— INSTALLER'S NAME&..PHONE NO. SEPTIC TANK CAPACITY I 50-6 LEACHING FACILITY: (type) —30 6-0 (size) NO. OF BEDROOMS-- ADUMDEROROWINEER � 3irVneg.,50(,j PERmrrDATE: COMPLIANCE DATE: -71ol 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 f6dt of leaching facility)* Feet Edge of Wetland and Leaching Facility (If any.wetlands-exist within 300 feet of leaching facility) Feet Furnished by ............. 0 - i , - .. 18, % 0 -3 L w r s { ... . ........... �i97 r r � i �J 1 � C � c � T w r� Qrlj As �rN I i � r �• W \ s � NJ% 1P �� �, y T Page 2 of 3 `�0 1 /' CLAUSSEN, FREDERIC P 2001-05-30 13883/314 $150000 F' KOSTKA, JOHN E & DEBORAH A 1996-08-23 10359/171 $1 KOSTKA, JOHN E& DEBORAH A 1994-04-15 9149/225 $24900 KOSTKA, JOHN E& DEBORAH 1987-07-22 5843/254 $117000 DORAN, MARK 1987-05-12 5716/52 $125000 DORAN, MARIE V 1987-01-29 5538/148 $110000 CUTTER, CINDY L 1987-01-15 5538/148 $110000 CUTTER, CINDY L 1986-05-23 5094/49 $98000 NICKULAS, LARRY D 1986-02-28 4944/112 $625000 TELLIER, EDWARD A &JUNE I 1964-07-13 1260/581 $0 • Photos 246/ 185/-Use Code: 1010 • Sketches- Map/Block/Lot: 246/ 185/-Use Code: 1010 �N As Built Cards:Click card#to view: Card #1 1 . Constructions Details- Map/Block/Lot: 246/ 185/-Use Code: 1010 Building Details Land Building value $ 61,400 Bedrooms 3 Bedrooms USE CODE 1010 Replacement Cost $94,430 Bathrooms 1 Full-0 Half Lot Size(Acres) 0.18 Model Residential Total Rooms 4 Rooms Appraised Value $ 240: S DATE PROPERTY ADDRESS 1 3 4 to Av •+ west HyannicPnrt. MA 02672 eptic system at the address above was On the above date, the Inspected. This system consists of the following:. 1., 1-1500 gq eion .6ept.ic .t.ank., 2.- 1-Di.3 Li?-Ut.ton 90x,� 3,, 3-3050 .in�.i2t2at-oz3 . Based on inspecdlon, I certlfy the following conditions: 4.� 7h.i..3 i.6 a 7.it ee Five 'he/2t.ic bybLem 5.,' Se/2t.ic 6y,3tem. .i - in j22o/Zea wo•2k.i.ng oadea at the /sae,6eat time. S.IQNATURE Name: Robert AAw Paolinl Company: �uarmher &Son Inc, Address: P. O. Boxes CenteryIII2. Mass MM, Phone: 508 775.333 or 5e2.775.M jOSEPH P. MACOMOER & SON,INC*, TankaCOUP001:•I.e chfieid: • �Pump�d &•:In:#ailed' T6WO Sewer'ConneCtlons 2-0066 P.O. Box 66 Centeiville, MA,026 WOW .•77.5.6412 i COMMONWEALTH 6F wSSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION J TTF E 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTWICATION property Address: 13 4 th Ave . W HyannisPort MA _02672 OwneesName- FraAAri C Cl alicaan Owner's Address: L r+ n g�f 132 Comm-b-A 02635 Name oflagpeetor.(plh? Robert A Paolini CompmyName; J_P_Macomber & Sop.. Inc. MaftAddresx Rox Fib Centerville MA 02632 TelepbowNumber:50.8-775-3338 CERTIFICATION STATEMENT I certify that I have personalty 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 performedbased on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system Inspector pursumt to Section 1SL340 of Title 5(310 CMR 15A00). The system: XXX Passes. Conditionally Passes Needs Further Evaluation by the Local Approving Audxsity � F's Inspector's Signature: i Date: 810105 The system inspector shall submit a copy of this inspection report to the Approving Authority.(Board of Healthior 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 summit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and 0me approving a w iit!. Notes and Comments - vThhs report a*describes couditiow at the time of Inspection and umber the comiitians of use at&a. tm This inspection does not address haw the system w0l perform in the future under the same or different condidensofbim Tide 5Inspection Form 6/1512000 lie i Page 2 of 11 OFFICIAL INSPECTIO.NYORM--.NOT FOR VOLUNTARY ASSESSM,IENTS . SUBSURFACE SEWAGE DISPOSAL Si(STEM INSPECTION FORK; PART A CERTIFICATION (continued) Property Address:J 'i 4 t h Ave a HyannjAPart MA n2F72 Owner: Froda i ni Date of Inspection: -A."I Q/n Inspection Sum`mary..: .Check:A;B,C,D or.E/A. WAYS<complete all of Section;D A. System Passes:geS NO. I have not found any information which Indicates that-iny of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: septic nyhtem .ins .in Paoflea woak.ing oadea at the Raa4ent time., B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass",:section need to be.replaced.or. repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass. Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic.tank is metal and.over 20 years old*.or.the septic,tank(whether metal or not)is:.structurally unsound,,exhibits substantial infiltration or exfiltration:or tank failure is imminent:System.will pass inspection if the existing tank is replaced with a complying septic tank.as approved by.the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old:is available. ND explain: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box.System will pass inspection,if(with approval of Board of Health)- broken.pipe(s)are replaced obstruction is removed distribution box,is leveled or replaced ND explain: NO The system required pumping.more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2• Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 4th Ave W HyannisPnrt MA _022672 Owner:. Frederic Claussen Date of Inspection:Ate/n S C. Further Evaluation is Required by the Board of Health: NO 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 31.0 CMR 15.303(1)(b)that the system is not functioning in a manner:which.will protect public health,safety and the environment: n oCesspool or privy is within 50 feet of a surface water n oo Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and-environment: no The system has aseptic tank and soil absorption system(SAS).and the SAS is within 100 feet.ofa surface water.supply or tributary to a.surface water supply. . no The:system has a.septic tank and SAS and.the°SAS is`within a Zone 1 of a public water-supply. n o The system has aseptic tank and.SAS and the SAS is within 50 feet of a private water supply well. n o The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or.more froN a private water supply well". Method used to determine distance vi.3ua e "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT'FOR-VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE:DISPOSAL;SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 4th Ave w HyannisPo_rt MA 02672 Owner: PrpdPric ClaLssen Date of Inspection:A/g f 0 5 D. System Failure Criteria applicable to all systems:. You must indicate"yes":or"no"to each of the.following,for all inspections: Yes No _ X Backup of sewage,into facility or system'component due..to overloaded.or.clogged SAS.or..cesspool _ X Discharge.or:ponding of effluent to the surface of the:.gruund or.surface:waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than.6"below invert or available volume is less than'%•.day flow _T Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ _T .Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply.: X Any portion of a cesspool or privy is within a Zone 1,of a.public well... _ X Any portion of a cesspool or privy is within.50 feet of a private water supply well. _ X Any portion of a cesspool or-privy is less than•100 feet but greater.than 50 feet from a private water , supply well with no acceptable water quality analysis..]This system..passes.if the well water:analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates..that the well is free from pollution.from.that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forrp,] NO (Yes/No)The system fails.lhave determined that one ofmoreipf.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 1.0,00.0 gpd to 15,000. gpd. You must indicate either"yes"or`.`no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Lnterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade.the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 13 4 f h A va W HyannicPnrt MA 02672 Owner: FrPriprin claiyssen Date of Inspection: 8 0 Check if the following have been done.You must indicate"yes"or"no"as to each.of the following: Yes No X_ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X 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)- X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? ' X _ Were all system components,42cluding the SAS,located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at(he Board of.Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.-SEWAGE DISP..OSAL.,SYSTEM-INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 4t-h AvP W HyannisPnrt MA 02672 Owner: Frederic C1aLSGen Date of inspection: 8/q/0 S FLOW CONDITIONS RESIDENTIAL . Number of bedrooms desi Number of bedrooms.(actual):." 3, DESIGN flow based on 310 CNIR 15'** (for example: 110 gpd z#of bedrooms):3 3 0. Number of current residents: 2 Does residence have a garbage grinder(yes or no):a o Is laundry on a separate sewage system(yes or.no)nb [if yes separate inspection required] Laundry system inspected(yes or no):n o Seasonal use?(yes orno):n.o 2003_39, 000, g.aleonz G/[0_106. 84 Water meter readings,if available(last 2 years usage(gpd))Z004=3 6, 000 pa Uon.3 G%[7=98.E 6 3 Sump pump(yes or no):n 0 Last date of occupancy: R 2 e,3 e n t COMMERCIALd. r6USTRIA� Type of establ�&hint: N .R Design flow(li'as6d on 310 CMR 15.203): imd Basis of diisign flow(seats/persons/sgft,etc.):, Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to-the Title 5 system.(yes or no):_ Water.meter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL.INFORMATION Pumping Records NIA Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume,pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption:system . _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank. _Attach a copy of the DEP approval Other(describe): A proximate age of all components,date installed(if known)and source of information: �. zta-eied 5/7/01 aogeats Were sewage odors detected when arriving at the site(yes or no):n 0 6 Page 7 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART'C SYSTEM"INFORMATION(continued) Property Address: 1 3 4 t h n ug= W HyannisPart MA 02672 Owner: Frederic ri aussen j Date of Inspection: 8/3/0 5 BUILDING SEWER(locate on site plan) Depth below grade: 2 4" Materials of construction:_cast iron X 40 PVC other4wl4iii): Distance from private water supply well or suction line: Comments(on-condition of joints,venting,evidence of leakage,etc.): ao..n.tz a1212ea1L t cghto No ieakageo Vented .tfr26ugh house vent SEPTIC TANK:y e's(locate on site plan) 15 0 0 ga e i o n Depth below grade: 18 n Material of construction concrete_metal fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_.(attach.a copy of certificate)Dimensions: 10 6n X 5 8 X 5 8 Sludge depth-7 a a c e Distance from top of sludge to bottom of outlet tee.or baffle:t a a c e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t a a c e Distance from bottom of scum to bottom of outlet tee or baffle:;t/ta c e How were dimensions determined: m e a z u a e d Comments(on pumping recommendations,inlet.and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): P umI2 tank eveAy 2 yeaah., Ineet .(f outlet tees as 1 an zz —zta--actuaaeey zoun GREASE TRAP: 2 Ylocate on site plan) Depth below grade._ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain)`. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from.bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Gaease taa .iz not ae-sent 7 Page 8 of 1 I. l .OFFICIAL INSPECTION.:FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART.0 SYSTEM.INFORMATION(continued) Property Address: 13 4 t h A vQ W HyannicPort MA 02672 Owner: Fr -d ri c C1 anccrmn Date of Inspection: 8 3/_0 S TIGHT or HOLDING TANK:n 0 (tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass_.:polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): Tigh.- 0a ho 2d.ing tdnkz acre not R eeen , DISTRIBUTION BOX:.Jeh (if present must be.opened)(locate on site plan) �. Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover,any evidence of . leakage into or out of box,etc.): Box .ins ieve-G Kas 2 2ate2aez., N.o_ .z.i nz. o �so2.id caaaw oven oa ea age In 32 ouz o ox., PUMP CHAMBER:NO (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 'l umI2 chamtZ4 i s* not R2eaent 8 Page 9 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued): Property Address: 13 4t-h Ave W HvannisPort MA 02672 Owner:. Frederic Claussen Date of Inspection: 8/3/0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see page 10 Type leaching pits,number: 3-3 0 5 0' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: . innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy to med.ium.. .3and., So.i2.6 ate day., No. .s-igns ol-A Za.ieu-e oa ponding., ege a .con .cis no2ma a CESSPOOLS: n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: . Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes�or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce s spooih aae not /22ezent PRIVY: no (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.): R2.ivy .i.� not �ze.5ent ..9 Page 10 of I 1 ✓ OFFICIAL INSPECTIONTORM:—NOT FOR—VOLUNTARY—ASSESSMENTS SUBSURFACE.SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT'I.ON(continued) Property Address: 1 3 4 t h AvP _W Rj&Anni cPnrt MA 02672 Owner: PrPde_ri_c 1 aussen Date of Inspection: 8/3/0 5 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100.feet.Locate where public water supply enters the building. i •ra,r r w. 0. l �3: 61' 10 Page 11 of 11 OFFICIAL INSPECTION•FORM—NOT FOR VOLUNTARY PON ORMNTS . �. SUBSURFACE SEWAGE DISPOSAL SYSTEM PART C' SYSTEM INFORMATION(continued) Property Address: 1 1 4th 4us w T4vann4aPnr4. MA 02672 z Owner: Frederi q c a17RSen Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells. Estimated depth to ground water feet • Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If wi�?�5� fet o design 1�Teviewed. y [/e b Observed site(abutting proP9riY/observatiop hole ^ry n _ Checked with local'Board of Health-explain:�� 9W1,94 n o Checked with local excavators,ins s-(attach hd0taa .a t o 9.9 a o m a.,u h. !2 ' ovn � n Accessed,0SGS database=explain — .—.. You must describe how you established the high ground water elevation: 11�sed Ca e Cod Comm.iz ion. 1dat eti 7a8 �e 1.995 tou2 a And Pub$ce 1Jat e2 'WeJ1 head zoteet�on ¢news ma S e •t Glaten 2esounce�5 0 .jce cana co eommcbcon.� Le -eet Groundwater Fcet Below Bottom'of Pit Hish Groundwater Adjustmdnt 1.8 ft per Frimpter Method Therefore,the vertical•separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. Z 0 ,Z— ' 11 . r a•n,tarn.-n.r.r•e-rrmrmrrsenrrnrtaa+rrermr.•e'+mrlvRrorrm rrvrn�a+o�rstatmen �sr•a-.rrtrr��:t:-.r••� TOWN OF RARNGTART.E BOARD. OF .HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION . --win�T•S�::t��tif."�TTIRST.fIt'Rt1Tt TtIR.4R7Ii'If' !7'1'r�.:'i TlitRR:'t.iRRRt�'�'�RJ7 }tPRR4lIA'7Qt7 iftllR .0"r.V T V, •.•.•� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ _ 13: 4th Ave ASSESSORS MAP, BLOCK AND PARCEL 42Y6 48�5 OWNER's NAME FrPdP4 C Cl a„acer, PART' D - CERTIFICATION NAME OF INSPECTOR Rogeat P aoiiri.i COMPANY NAME aozeph. P.- Nacomge)r T Son Inc COMPANY ADDRESS Box 66 Centenv4_'iie Mass 02632 Street' Town or City. .9tate LIP COMPANY TELEPHONE ( 508 V 7:75 - 3338 FAX ( 508 b90 - 1578 rlt R , CERTIFICATION STATEMENT I certify that I have personally. inspected the sewage disposal system 'a t 01this address and that t}ie information. reported is true , accurate, .and omplete as of the . time .pf .inspection . The inspection was performed and any r_lecommeiidations regarding upgrade , . maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: ; System PASSED ' The inspection which I have conducted has not found any information which indicates that. the system fails to adequately protect public health or the enviropmerlt as defined in 310 CMR. 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con tcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 30.3, and as specifically noted on PART C FAILURE CRITERIA of this inspecti n form. e Inspector Signature Date Xri3�J . scopy of this certification must -be provided to the OWNER, the. BUYERhere applicable) and tha BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade ' the system. within one year of the date of the inspection, unless allowed or requi,re.d otherwise as provided in 3.;10 CMR 16 , 305 ,