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Home My WebLink About0010 FRESH HOLES ROAD - Health 10-12 Fresh Holes Road �a Hyannis-- P-- - - - A ,' 292 185 ' a I u ° 6 n a o ° i I� r ° o o a 1 n 1 a 0 o , I. I o2902- Commonwealth of Massachusetts �o Title 5 Official Inspection Form r=t Iu.H� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's N information is k�r required for every Hyannisam Ma 02601 1-21-19 g page. City/Town State Zip Code Date of Inspection�fl 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 sly (3(a&3 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. Co Route 130 vy Company Address Sandwich Ma 02563 City/Town State Zip Code rmv (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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 I 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 1-21-19 ,. d1o:10B.01.t50]^J.:45 dSW 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 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. l5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Ccmplete 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 system was in working order 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. I *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): i l5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 v Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes v Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, ` safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 'The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. I ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El 0 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes V Property Address Ronald Bourgeois Owner Owners Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ 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? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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, din-ensions, depth of liquid, depth of-sludge and depth of scum? ❑ El 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: El ❑ Existing information. For example, a plan at the Board of Health. ' ❑ El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c� Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 10-12 Fresh Holes Property Address Ronald Bourgeois - Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440/gpd Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes (E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2017-74,052Gallons 2018-112,200gallons Sump pump? ' ❑ Yes X *No Last date of occupancy: currentDate t5insp.doc•rev.7262018 Title 5 Offidal 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 10-12 Fresh Holes Property Address , Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: • Type of Establishment: NA • Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancyruse: Date . Other(describe below): 3. 'Pumping Records: Owner- last pumped 18 months ago 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: t5insp.doc-rev.7/16=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address _ Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: COC dated 3-22-2000 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' I Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallons Dimensions: 10" Sludge depth: 26" Distance from top of.sludge to bottom.of outlet tee or.baffle Err Scum thickness. 41r Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time oflnspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet j Material of construction: i ❑ 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: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of 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):, Orr 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.): The d-box was in working order at the time of inspection. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes L Property Address Ronald Bourgeois Owner Owners Name information is Hyannis Ma 02601 1-21-19 required for every y St page. CitylTown ate Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes Q No* Alarms in working order: ❑ Yes 9 No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: (5)hi cap infiltrators 0 leaching trenches number, length: ❑ leaching fields number, dimensions: '❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7262018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town 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.): The leaching was in passing condition. Infiltrators were 3/4 full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid tc 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 n Commonwealth of Massachusetts Title 5 Official Inspection. Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes L Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y 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 Assessing As>Built Cards LUW,N Ur b.AX ,x1PWL.0 /y�`�•/' IXATION 1A-.y./n_ Fae a ll„L r SEWAGE Va.LAOE .iJ_v�.c=.✓ ASSESSOR'S'MAP do LO'j'�S INSTALLER'S NAME&PHONE NO. _g i A c V ra,, t -rh fi c 9 sEPTic TA-Nx cAPAcrrY LEACHING FACU TTY:(type) (size) NO.OF'BEDROOMS- ,T_ D PDX BUILDFdt OR OWNER PERMTTDATE: COMPLIANCE DATE; _ Separstion.Distanee Between the: Maximum Adjusted Giramdwaler Table and Bottom cc Leaching Facility Feet Ptivtue Water Supply Well and Coaching Facility (If any wells exist on site or within 200"(bet of toachiny facility) Up of Wotlsnd and Leaching Facility(U any wetlands'exist within 300 feat of leaching facility) Tent Fturlished by A IA_a g t5insp.doc-rev.7/262018 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 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope FE] Surface water ■❑ Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: . 3-17-00Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. r l - r 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 , I Commonwealth of Massachusetts �= Title 5 Official Inspection Form i I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10-12 Fresh Holes Property Address Ronald Bourgeois Owner Owner's Name information is Hyannis Ma 02601 1-21-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sectionsrof this form inclusive of: ■❑ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked W 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 Inspedon Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovarnick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. CdyfTown 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. General Information on the computer, use only the tab 1. Inspector: I key to move your cursor-do not Kevin Cochran use the return Name of Inspector key. Aardvark Environmental Inspections 2y Company Name PO Box 896 Company Address East Dennis MA 02641 Citylrown State Zi Code o 0 508-385-7608 SI 13356 Telephone Number License Number _.. ` • B. Certification V I certify that I have personally inspected the sewage disposal system at this 1hat t1ro �;! information reported below is true, accurate and complete as of the time of the inspehon.The lvspecj-& was performed based on my training and experience in the proper function and maintlenance ofaart sit6' 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 Evaluatio by the Local Approving Authority 1220/13 Inspectors I r 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. U. dI I ► I t5ins•11/10 Title 5 Offic' tion Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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): Wins-11/10 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 mash t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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•11/10 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. i ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or°no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered `yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5Offcial 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is Hyannis MA 02664 12/15/13 required for every H y , page. City/town 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? ❑ ® 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 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 10-12 Fresh Holes Road Property Address Jason Bovarnick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date CommerciaUlndustrial 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis annis MA 02664 12/15/13 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: 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) (f 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 03/17/00 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.7 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: 2.4 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: 1,500 gal 5r, Sludge depth: t5ins-11/10 Title 5Offcial 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 t of 17 i <C\ Commonwealth of Massachusetts Title 5 Official Inspection Form ug Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 10-12 Fresh Holes Road i Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityfrown 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 even 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.): The box was level and tight with no sign of carryover. j Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): This system has 5 infiltrators surrounded by 4 feet of stones.There was no sign of ponding or failure in the stones. 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 toins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form sl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovarnick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins-11110 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 Forth-Not for Voluntary Assessments 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityrrown 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 ftont 16 52 39 52 35 55 t5ins•11/10 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityfrown 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: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. . i Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 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 10-12 Fresh Holes Road Property Address Jason Bovamick Owner Owner's Name information is required for every Hyannis MA 02664 12/15/13 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I [Sins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 05/22/2012 12:13 5083944819 BASS RIVER PROPS PAGE 02/03 a: 3.iber Vr.opertieo 150 Nain Street Wes%Dmnu,WA 02670 i' 508,394-4446 eFdX,508-394-4819 'WCV'w•�pss�,rve►�PYo�es'tie�cunt • "Cape Coefs TuITService fta&y Company b NOTICE FOR BED BUG INSPECTION Preparation is important to the success of your treatment. The more thorough the preparation, the better the results of the treatment will be. Therefore Waltham-Chemical's first appointment will be an inspection of the property to see the current conditions of each unit. The following pages include information and steps the tenant should take to make this a successful inspection and for the future extermination. If you are not going to home, please call Errol at (518) 210-7842 to make sure we have access to your unit. If you have any questions, please feel free to call us prior to the treatment date (508) 394-4446, Monday through.Friday, 9:00 am to 4:00 pm YOUR TREATMENT AT 10-12 FRESH HOLES ROAD, HYANNIS, IS SCHEDULED ON: WEDNESDAY, MAY 23, 2012 FROM 9:00 AM - 5:00 PM. THANK YOU RONNIE i 05/22/2012 12:13 5083944819 BASS RIVER PROPS PAGE 03/03 Bed Bug Pre Treatment Walt a Post Treatment Ike end 7..Le,('M"l sut"Ism Instructions rx i }f�rTr. atlenrr 1.Remove all bedding(sheets,mattress pads etc.)from beds. Wash,dry and store bedding in a sealed plastic bag. Running bedding through a clothes dryer on the hot setting alone will also work. (Beware of fabrics damaged by high heat.) 2.Bedside night stands,bureaus and closets should be emptied. Place the contents in sealed plastic bags. 3.Wash and dry all clothing and then seal articles in a tightly closed plastic bag. 4.Remove all storage from the floor of the living room and bedrooms. S.Furniture should be moved at least 18 inches away from walls to provide access for inspection and treatment. 6.Pets,including fish and birds should be removed to protect them. 7.Remove food items from rooms to be treated 8.Vacuum around records,Cps and books.Seal and dispose of the vacuum bag 9.All rooms and closets should be left unlocked to allow for inspection and treatment. 10.In heavily infested homes and apartments,carpeting should be untacked and rolled back at the edges,and cove molding removed for treatment. 11.The bathroom should be left empty,as it may also need treatment 12.Do not use aerosol insecticide sprays,as this will chase the insects into new hiding areas and may cause them to spread. NOTE: The omount of assistance and cooperation affected residents provide ditecdy influences the quohiy of the treatment and the level ofbed bug control.the fabric covering underneath upholstered furniture wdl be removed to offbw for inspecBon and treatment,unless unitresidents request otherWse.Objects WN be removed from the wall farinspection and treatment by service personnel.Residents should remove dellbote and valuable object Valuables should be put away orremoved After the Treatment 13.Allow mattresses,box springs and othertreated areas to dry before reassembling the room. Opening windows,and tuming on heat or air conditioning will help things dry quicker.Beware of freezing in the winter,if opening windows. 14.Avoid bringing infested furniture,mattresses,box springs and bed frames home. 15.Inspect and vacuum-dean luggage when retuming home from trips,or when having visitors. 16.Wrapping pillows,mattresses and box springs in zippered,bed bug proof bags will protect these articles and keep them dean and bed bug free 17.Follow-up visits to heavily infested homes should immediately be scheduled(within 2-4 weeks). Full re-treatments should be made with complete preparations. 18.Lightly infested residences should be reinspected within 2-4 weeks and spot treated,where necessary. Photos cou rtesy of M.Potter, I�li 4 Univ.of Kenmcky 6 m 2010 Waltham Services &2010 i Page 1 of 5 O'Connell, Timothy From: Jodi McDonald [Jodi_bassriverproperties@yahoo.com) Sent: Tuesday, May 29, 2012 9:52 AM To: Mike Russell Cc: ron@bassriverproperties.com; O'Connell, Timothy Subject: Re: 10-12 Fresh Holes Road, Hyannis Thank you ! ! ! I will let her know Jodi McDonald Bass River Properties " Cape Cod's Full Service Realty Company" 150 Main Street West Dennis, MA 02670 Office 508-394-4446 extension 4 N Fax (508) 394-4819 Monday N Friday, 9:00 am to 4:00 pm From: Mike Russell <MRussell@walthamservices.com> To: Jodi McDonald <jodi_bassriverproperties@yahoo.com> Sent: Tuesday, May 29, 2012 9:14 AM Subject: RE: 10-12 Fresh Holes Road, Hyannis Hi Jodi, This is sched for Friday 6/1 early afternoon. Mike Mike Russell, Area Rep - Boston Metrosouth, Cape and Islands Waltham Services,LLC. Pest&Termite control since 1893 p 800-542-2079 f 781-331-1523 mobile 781-760-3273 mrussellQwalthamservices.com www.walthamservices.com From: Jodi McDonald [mailto:jodi_bassriverproperties@yahoo.com] Sent: Fri 5/25/2012 1:46 PM To: Mike Russell Cc: ron(c�r�,bassriverproperties.com Subject: RE: 10-12 Fresh Holes Road, Hyannis Hi mike. I spoke with board of health and said you are the expert so we only have to do 12. Please could you schedule for Wednesday or after. Just so I can give notice to 12 fresh holes. 5/29/2012 Page 2 of 5 Thanks so much Sent from my Samsung Epic(tm) 4G Touch -------- Original message -------- Subject: RE: 10-12 Fresh Holes Road, Hyannis From: Mike Russell <MRussellQwalthamservices.com> To: Jodi McDonald <jodi bassriverproperties ,yahoo.com> CC: ron@bassriveLproperties.com Jodi, Are you saying you need to have bothl0 and 12 treated? I only quoted unit 12. There was no evidence in 10 but we can do a perimeter treatment as a preventative that way it will show as treated. It will be an additional $100, please confirm via email and I will get scheduled. Mike From: Jodi McDonald [mailto:jodi_bassriverproperties@yahoo.com] Sent: Thursday, May 24, 2012 6:49 PM To: Mike Russell Cc: rongbassriverproperties.com Subject: RE: 10-12 Fresh Holes Road, Hyannis Unfortunately by law if it is a multi unit, the landlord must do all units. The health department is involved so they both should be done I was told. Ronnie faxed the contract back to you. Hope you received it. Hoping to get this done next week if possible. Let me know so I can give tenants notice. Thank you. Sent from my Samsung Epic(tm) 4G Touch -------- Original message -------- Subject: RE: 10-12 Fresh Holes Road, Hyannis From: Mike Russell <MRussell a,walthamservices.com> To: Jodi McDonald <jodi bassriverproperties@yahoo.com> CC: 12 Fresh Holes is very clean, and 10 does not have any. 5/29/2012 ' Page 3 of 5 From: Jodi McDonald [mailto Jodi bassriverproperties a,yahoo.com] Sent: Thursday, May 24, 2012 3:00 PM To: Mike Russell Subject: Re: 10-12 Fresh Holes Road, Hyannis Hi Mike, Great!!! I printed out the contracts for Ronnie to look over so hopefully I will get those back to you next week. When I sent the tenants notice of the inspection I also sent them the instructions as well so Im glad you emphasized them. I do have a question however, 12 Fresh Holes needs more cleaning? She states that someone could eat off her floor. Im just curious. Maybe it was 10 Fresh Holes. lol. Some tenants just make me laugh. I will definately keep on the two apartments to be ready in the mean time. So I do want to make sure it is 12 Fresh Holes, which is the tenant who called first. 10 Fresh Holes claims that they do not have any. Please verify that with me. Thank you for your hard work. Jodi Jodi McDonald Bass River Properties "Cape Cod's Full Service Realty Company" 150 Main Street West Dennis, MA 02670 Office 508-394-4446 extension 4—Fax (508) 394-4819 Monday —Friday, 9:00 am to 4:00 pm From: Mike Russell <MRussell a,walthamservices.com> To: Jodi McDonald <jodi bassriverproperties yahoo.com> Sent: Thursday, May 24, 2012 1:46 PM Subject: RE: 10-12 Fresh Holes Road, Hyannis I Hi again Jodi, We inspected these yesterday and I have attached proposals for treatment. These require 2 treatments; one initial and one follow up. I gave the tenants in 44 Yarmouth#2 and 12 Fresh Holes preparation sheets (instructions) and have attached one here for your info as well. The apts below in 44 Yarmouth will not need to prepare as they are ready now. Let me know if this is appeoved and we can schedule. Mike From: Jodi McDonald [mailto:jodi_bassriverproperties yahoo.com] 5/29/2012 I Page 4 of 5 Sent: Tuesday, May 22, 2012 12:48 PM To: Mike Russell Cc: ron@bassriverproperties.com Subject: Re: 10-12 Fresh Holes Road, Hyannis Oh that would be awesome, Mike. I am going to just give them a window of 9am to 5pm just like the others. thank you so much. Jodi Jodi McDonald Bass River Properties "Cape Cod's Full Service Realty Company" 150 Main Street West Dennis, MA 02670 Office 508-394-4446 extension 4—Fax (508) 394-4819 Monday—Friday, 9:00 am to 4:00 pm From: Mike Russell <MRussellgwalthamservices.com> To: Jodi McDonald <Jodi_bassriverproperties@yahoo.com> Sent: Tuesday, May 22, 2012 12:36 PM Subject: RE: 10-12 Fresh Holes Road, Hyannis I can do after or before the 44 Yarmouth, whatever works for Errol or the tenant.. Mike From: Jodi McDonald [mailto:Jodi_bassriverproperties@yahoo.com] Sent: Tuesday, May 22, 2012 12:00 PM To: Mike Russell Cc: ron@bassriverproperties.com Subject: 10-12 Fresh Holes Road, Hyannis Hi Mike, We have another bed bug situation at 10-12 Fresh Holes Road, Hyannis. Please let me know if you can help us there and if so, when you can go out there to inspect. Thanks, Jodi Jodi McDonald Bass River Properties "Cape Cod's Full Service Realty Company" 150 Main Street West Dennis, MA 02670 Office 508-394-4446 extension 4 —Fax (508) 394-4819 Monday—Friday, 9:00 am to 4:00 pm 5/29/2012 No. VVV�� 12 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _�l Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplicatton for 33igpaal 6pgtem Con5trurtton Permit Application for a Permit to Construct( )Repair',)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /' Owner's Name,Address and Tel.No. Assessor's Map/Parcel > 2q Z-($ Insta�ller's Name,Address,and Tel 9 Designer's Name,Address and Tel.No. /J,0G(17ee rSbJ e/r avG-ZFoD Type of Building: Dwelling No.of Bedrooms_ Lot Size 13 q.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d gallons per day. Calculated daily flow 4M gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. S_ hlti S CA- Description of Soil Nature of Repairs or Alterations(Answer when applicable) h�PCC 0,�? Wa yS e T /ig,,,7,1 Date last inspected: Agreement: The undersigned agrees to ensure the construction an atnte nce of the afore described on-site sewage disposal system in accordance with the provisions of T' e of the Envi me Code and not to place the system in operation until a Certifi- cate of Compliance has been issue /lgy i o Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. SQ0 3—(2( Date Issued 3 L d3 �:w:� Kar. 'bi.' .. .. w ... -.� ....-w..•--�..-ate.- ,�. .,.-=....w W. r-�--.-..-_.- ... _ .. '.*--:w,*:-..s.-- -:iy -aa.�'Y :w4""i""�'�'�+?•R°}�1�7i�1]fa.;','T,"..�,-�`�T..`�.��"��".�7'�a: h u 2003- 12 Fee S� _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migpoml *pgtem Congtruction Permit Application for a Permit to Construct( . )Repair K)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Ma /Parcel P I Installer's Name,Address,and Tel No. �' r Designer's Name,Address and Tel.No. 2 6�6 ; . 'fir_•.,.:,.,•+�: Type of Building: ' Dwelling No.of Bedrooms Lot Size , fIue-t-sq.ft. Garbage Grinder( ) Other 'Type of Building 1 etl 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 ��Dd Type of S.A.S. S Description of Soil :Nature of Repairs or Alterations(Answer when applicable) �t/o,ee, � Wa elS-e T� /?e7/r P Y Date last inspected: s. Agreement: ; The undersigned agrees to ensure the construction an atnte ance of the afore describz d on-site sewage disposal system in accordance with the provisions of Title of the Envi nme Code and not to place the system in operation until a Certifi- cate of-Compliance has been issued'by ii odqfffealtr ; Signed Date -Application Approved by Date -3 Application Disapproved for the following reasons y Permit No. Date Issued 3 2 03 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance `THIS IS TO-CERTIFY, that the On=site Sewage Disposal System Constructed( )Repaired A ) Upgraded ( ) Abandon ( )by AF' at t) ( i e�4 «� has been constructe4 in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No.24U3-/2/ dated 3 ?8 G Installer Designer The issuance o this ermit shall not be construed as a guarantee that the systemVAtsir , Date J 2S 63 Inspector No. 2 UU j—(21 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0tzp gal bpgtem Congtruction Permit Permission is hereby gr nted to Construct( ) air K)Upgrade( )Abandon( ) System located at /D / 2 /-rash e s /Y y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construc •on mus be completed within three years of the date of this permit. Date:_ 2 1103 Approved by C011NOMVEALIH OF MASSACH SETTS cuTwE OFFICE OF ENVIIRONmNi'AL AFFAIRS DFPARTmNT OF.ENMR0N=NTAI:-P E® r 6• OCT 2 8 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE.5 OFICLAL NSPECTIO 1-FORM. ----NOT FORTOLUNTARY ASSESSsIIE'NTS . i SIBSU"ACE SEWAGE I$ISPOSAI.SYSTEM E+ORIM PART A CERI IFICATION MAP Property address:id 'cr PARCEL +ner's aexae: /©t[� �7 ; .ram z_2 ;ti LOT Owner's Address- Bate of'Snspeetion:_1 o / v 3 Name ofInspector: (please print) �y-Vz -41-4.1/4-10rasJ�X�t.� �T Compaa_y Name:AsLe Mailing Address: lapse- i �yy'Aiyryr Telephone Number. CE T€FICATION STATEMEENT 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 perforaned based oti my training and experience in the proper Ru ction-and maintenance of on site-sewage-disposal-systems.. am a DEP approved system inspector._.pursuant to.5ectign 15.3 30 of Title 5(310 C . S-M). The system: ! �Passeg Conditionally Passes _NeedsTurther Evaluation by the Local Approving Authority Pails Inspeetoes Sign Date: le 4_.3 ire system inspector shall submit copy of this inspection report to the Approving authority(Board of Healddh or EEP)within 30 days of completing this inspection_If the system is a shared system or has a design flow of I O.!00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of rite DER The:original should be sent to the system owner and copies sent to the buyer,if applicable,and the appr�•�ing authority. Notes and Comments i i '',*** 'his report only desetibes 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 camp nr diffaront Page 2 of 11 OFfICL41 WSPECH-ON FORM'—NOT T FOR VOLUNTARY ASSESSa .INS' S TAR' 'A 2ERMCAMN(saantinued) Property Address: Wi11 Y4nJ>v; „g Owner: cc.<6, ,` Date of Inspection: Inspection Summary: Check AAC,ID or E/ALWAYS complete 8I of Sedim D A. sysfe�-Lasses:. . l I have not€ouiad any information-which indicates that any-of the failure criteria described in 3-10 CMIR. 15,303 or in 3 IO'CMR I5.304-exist.Arty failure-criteria-not evaluate are-indicated below_ Comments: I$. System Conditionally Passes:. One or more system components as described in the"Conditional P4.1 section-.need to be-replaced er repaired.-The system,upon completion of the replacement-or repair,as aved by the Board of.Health,wiiI pass. Answer yes,no or not dete ed(Y,N,ND)in the .. for the follo g-statements.If"not determined"please explain. Y The septic tank is meta` and er-20 years old{or the septitank(whether metal.or not)is'structtuall unsound,exhibits substantial iuifiltratin or exfiltratian aar tank- &hMMiMML System will pass.iaspectios ifibb existing tank-is rep geed with a tank as sppro by-ffie Bawd of Health. *A metal-septic lank will pass inspection if i 's sinactsarally s not leakhm and if a Certificate of Compliair,e indicating-that-the tank is less than 20 years -II!- ,asaaelably ND explain: Observation of sewage backup or briak oast aar Static -level in the.distributia .box.due to brokim or- obsttWed-pipe(s)or due to a broken,settled ortBa soibu�km box.System will pass.isnspec;don if(with approval of Board of Health): broken .me d . obst-i ucti -removed. distnib -box is ND explain: The system,required pumping m .e dirt!l times a year due tor. roken or.obstructed i (s).The system win .P� Pass inspection if(with approval o£th oa"d of Health): roken-pil*s)-are replaced -obstruction is-removed ND explain: Page 3 of 11 OFPICL41 INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 U / Owner:Ile ez-A� 477"• 11- Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require finther evaluation by the Board of Health in order to determine if the system is fai3ing to protect public health,safety or the onment 1. System will pass unless Board of Health de es in accordance with 310 tLMR 15.303(I)(b)that the system is not functioning in a manger whir protect public health,safety and the environment: _ Cesspool or privy is within 50 fe, f a surface vE _ Cesspool or privy is within 50 �t of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public`dater Supplier,if any)determines that the system is functioning in a manner that protects a public health,safety and environment: _ The system has a septic tank and sail abs system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water ply. _ The system has a septic tank and SAS and the SAS' within a Zone I of a public water supply. The system has a septic tank and SAS and the S wt 50 feet of a private water supply well. _ The system has a septic tank and SAS and t SAS is less than�],OQ feet but SQ feet or more from a private water supply well**-Method used to ermine distance **This system passes if the well water ysis,performed at a DEP terrified laboratory,for cofiform bacteria and volatile organic compo indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A co , of the analysis must be attached to this form. 3. Other: Page 4 of I I F: T OFFIML INSPECTION.FORM—NOT FOR VOLUNTARY"} SE9�� MOTS SUBSURFAtE SEWAGE D►iSPOSAL.SYS :INSP N FOIE PART A CERTMCATION(coutinueO Property Address:/111 Owner:A ace Date of Inspection: D. System Failure Criteria applicable to all systems:_ You must indicate`fires"or"no"to each of the following for aII inspections: Yes No _ -Backup of sewage into facility or rystem component due w 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-dueto an-overloaded or clogged SAS or cesspool /,i tquui depth in cesspool is less than 6'below invert or available-volume is less than'/2 day flow — —/Required pumping more than 4 braes in the last year NOT due to clogged or obstructed pipes}.Af umber Of tmaes 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 smL-ce water supply. _ ,,,,"water 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. 77 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-qualityanalysis•[This system passes if the well water analysis, performed at a I✓EP certified laboratory,for coliform.bacteria.and volatile organic compounds indicates that the weif is free from pollution from that facility and the pmence.of ammonia. nitrogen and nitrate nitrogen is equal taa or less :5 ,provided-that no other film eviftria are triggered.A copy of the analysis-mad Lem.to-this fines.). (Yes/No)The system fails:1-have determined that one or more of the above failue-rdberia exist as described in 310 CMR-15303,therefomibe system fails=..The system owner.should contact the Board of Health to determine wharwili bevecessary to correct the failure. L Fargo Systems: To be considered a large system the system soma facinty.with.a..desiga fw of 10,000 gpd to 15,0000 mpd. You must indicate either`yes"or-no"to each of the-following: (The following criteria apply-tor sslerin addition to the criteria above) rgg yes no T — the system is within 400 feet off sitrfac water supply the m is within 200 feet ' a tri to a surface.drinkin water supply —— � � b�Y g — — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a ma-pped Zone II of a public water supply well x 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 hasfaiiled.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 CMI R 15304.The system,owner should contact the appropriate regional office of the Department. -Page 5 of I I OFFICIAL INSPECTION F01I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO§AL SYSTEM INSPECTION FORM PART B �CHEnCKLIST Property Address: aN:ti=J Ovner:llo u,o;L s W, a Date of Inspection: _4Z4 _3 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? t 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? F 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? ZWas 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: Ye /no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] Page 6 of I I t OFFICIAL INSPEMON FORM=NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURYACE StWAGE-MPOSAL'SYSTEM'I4SPECTIOW FORM s' RART C SYSTEM Eff ORMATTON Property Address:la i. :2 LS I Owner: �•� �1,/.�,i 1 Date of Inspection: !o 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design). Number of bedrooms(actual): DESIGN flow based on 310 .1 203(for example: 110 gpd x i#of bedrooms): Number of current residents: �I Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):�Z [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):_ Water meter readings,if available(last 2 years usage(gpd)): O 25... . Sump pump(yes or no):yti/ Last date of occupancy: 02 i D-3, COMMERCIALA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15. 3): gpd Basis of design flow(seats/ o ft,etc.) Grease trap present(yes or no Industrial waste holding tank p sent(yes or.no): Non-sanitary waste discharge the Title 5 system(yes or no): Water meter readings,if a able: _ - Last date of occupancy/use: OTHER(describe): GENEJUL—INFORNTAnON Pumping Records Source of information,- G� - W as system pumped-as iiartof the-inspection(yes or no)- If-yes,volume pumped /.��4_) lons=Hbw-was: pampei.de—Wrmnied?-/.dL�✓�/r IAIL��54,1t Reason for pumping. XfS"5 sa�� s iry J T ptr SYSTEM— Septic-tank,distribution bow soil absorptiaa systm Single_cesspool 6verfl6r cesspool —_Privy —Shared system(yes orno)-(if yes,attaclrpteviaus mspection-records--,if any} _Innovative/Alternative technology:Attacker copy of the current operation and maintenance contract(to be obtainedfrom-system owner) - _Wight tank _Attach.a-copy of the DEP-approval Other(describe): Approximate'aQe of all coMpopents,date installed{if known)and source of info�r(mation: PIP Were sewage odors detected when arriving at the site,(yes or no): lkee7ofII OFFICIAL INSPECTION I'®R!' NOT FOR VOI,,'MAR ASSESS S SUBSPACE SEWAGE DISPOSAL SYSTEM.INSPEC ON FORM PART C SYSTEM DW® ATION(continued) Property Address:r u ZZ n tr S k�51 -fir.a,✓,,..�� .� Gwnerl A /2 711 Date of Inspection: �a� BUILDING SEWER(locate on site plan) Depth below grade: — 14aterials of suction: oast iron d'''4p PVC other(explain}: Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): S,EMC TANK: ,---60cate on site plan) Depth below mde:�� ]Material of construction: 'concrete metal fiberglass polyethylene other(explain) If tan-1 is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy j� certificate) Dimensions: [d.,-y S fudge depth: Distance from tap of sludge to bottom of outlet tee or battle: A0 i� Scum thickness: • Distance from top of scum tv top of outlet tee or baffle:_ Distance from bottom of scan to bottom of ontlet tee or battle: L3C%e" Fow were dimensions determined: A !!,IQ v�_a j Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid le.-Ts as related to outlet invert evidence of leakage,etc.): RFASE TRAP: (locate on site plan) Depth below grade:— Material of construction:ooncnete etal fiber-glass_polyethylene other (explain): Dimensions: S,-um thickmess: Distance from top'of s e: Distance from bottom f s to bottom of outlet tee or bade: Date of Last Pumpin 5x. Canunents(on iecommendations,_inlet and.outlet-tee-0r baffle condition,structural irte as related to outl evidence of leakage,etc.): icy,Iignid levels Page 3 of 11 ``a'3'd'L1Lt lr WSPEC,7nb OfliM t�7 FORNOLUNH'ARY- ESt91sfMNTS , . •Y' "Y' SY STEM INFORMAMON(b t ued)- owner-z_/,/� Doti of�a&i: IGHT or HOLDING TANK; (tank;rrnst be pumped aYtinie ofhspecti= re on siteplaa) .. Depth below grade: Material of conszructian: concrete metal fiberglass__jmbethyjme oth.=(e plaia): Dimensions: Capacity: ✓ gallons Design Flow: gaiIonslday Alarm present(Yes a Alarm level: iai wcrg.ord Date of last porn g (Yes or no): ammerrts( cgn crf alarm.an Moat swit6es,etc.): D1« 1<i33�3o (ifpresent must be openWocate on site plan) Deptb of lignid leimi-alwve-autlet invert: CommeM(note if box is level and.dis6&tm oz to outleM=jVAWW evidgaue_of solids-carryover,any evidscz Qf 3eakage inta or out of box,etc.): ..{locate sitepIaiti Pumps in worldag order{yes o o): - Alarms in working order(yes r ) Cammetits{note coign© pump chamber, ion$t"pumps aid ..... �ces, I - j r - Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) f n Property_Address:./ Owner:/ e'i A&ell � ,•✓.�L Date of Inspection: /0 �q_/T C)3 SOIL ABSORPTION SYSTEM.(SAS): locate on site plan,excavation not required) If SAS not located explain why:�7 _ V J7/ t� L' i'� �.S'fti ��/j �� 2 4; r ✓L r Ili,,+ / Type leaching pits,number. - leaching chambers,number: ,,'leaching-galleries,number. leaching trenches;numbei,length: leaching fields,number,dimensions: overflow-cesspool,member. innovative/alternative system -Typelname of technology: Comments(note-condition-of soil,-signs of hydraulic failure,-level ofponding=damp soil,condition of vegetation, etc.): 5 ri !.'pry�.o// �% /9� <si/7 )'� 1�3 .t �e=.U}''c �isi`.0 •iS CESSPOOLS: (cesspool must be pumped as part of inspection)(iocate on site plan) Number and configuration: Depth-top of liquid to inlet.invert: Depth of solids layer. Depth of scum layer. /" Dimensions of c ooe Materials of co c Indication of goon ow(yes or no): Comments(note c ditton of soil,sign of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate onAfi Ian)- Materials of construe' n: Dimensions: Depth of solids: Comments(note con itio .o soiI,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i Page 10 of I I 0FFICIA1,IIVSPEM0N-FORM—NOT,FOR VOLUNTARY ASSESSME T SUBSURFACE SMAGE-DISPOSAIL YSTEMINSPECTION FORM t> PART-C. SYSTEM IIVFOR-MAT.ION(confmued)., Property Address:. l aXa A is 2 it-'a•B2 ' + ' ®weer:. a � � U: n.•�:•1 . Date of Inspection: .,,e 2 t B SKETCH Old SEWAGE DISPOSAL SYSTEM-. Provide a sketch of the sewage disposal system inchiding ties to at-least two-permanent reference landmarks or benchmarks_-Locate aflwells within']00 feet Locate where-piiblicwatersupplyenters•the-building. /93 _ - TOWN OF BA-FIISTABLE E •�' jL��CP 1 ON. iZ --Y l® c!:A, � � SEWAGE #aw-1613 VILLAGE ASSESSOR'S MAP & LOT FS 111STALLER'S NAME&PHONE NO. !D c,4 42 e. X—e.n;' i SEPTIC TANK CAPACITY LEACHNG FACILITY: (type) ;,y,<i/r"/'0/'1 S (size) S NO.OF BEDROOMS / T QOX BUILDER OR OWNER PERMTTDATE: 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 • � � rr. �Y 1 '�. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migogat bpgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(vl/Abandon &Complete System ❑Individual Components Location Address or Lot No. I —f - Owner's Name,Address and Tel.No. Assessor's Map/Parcel D�-_ installers Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) "' ' ' • Other Type of Building TT No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title �✓ ��✓ T C. Size of Septic Tank �- (JD of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �V A� Date last inspected: I Agreement: i 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 i Signed Date 1 Application Approved by ® Date Application Disapproved for the following reasons Permit No. Date Issued TOWN OF BARNSTABLE I LOCATION -11 Y IQ r/tom s ,/_ �' SEWAGE #42 VILLAGE ie i ii.ri..r�i c ASSESSOR'S MAP & LOT_ i c)I INSTALLER'S NAME&PHONE NO. /n /A c,g42.r :...r T 7"ir SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /T/L/TUl2 S• (size) i NO. OF BEDROOMS H Z T PO BUILDER OR OWNER PERMTTDATE: 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 7-7 F�! N C .. � ti �..r / rr.. ..rsv.. , .. .. - .• .. ".. , - .._..-i ... �.i., 1. -;-*!t`s±i:% Fee O - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' 01pphratton for Mtgw6al *pgtem Congtrurtion Permit Application for a Permit to Construct( )Repair( )Upgrade(�,/Abandon( ) I.Complete System ❑Individual Components Location Address or Lot No. 1/1eS Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�— Installer's Name,Addressi:and.Tel.No g :) ,,• Designer's Name,Address and Tel.No. � �,ws..• 1lEiC� G �� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other,' Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures A. Design Flow gallons per day. Calculated daily flow A ,-� gallons. Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank k!�QD �✓�Type of S.A.S. C: !�L,C ''t � Description of Soile�CU 4r3 �•�51P+� Nature of Repairs or Alterations(Answer when applicable) µ- 5�Or' �--YC. �L r. �G`r� tti, C L.\✓`ZG LA-, e,( �V Date last inspected: l 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 iss .dby-t�iis Boaitti.— -- - - t Signed Date��'co Application Approved by D ate Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comphanre , THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( Abandoned( )by at has be� constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated / Installer Designer 1 The issuance of this permit shal�not be construed as a guarantee that the system-wil�fu ct, as d��signed�/� Date � Inspector At l�4 A ----�—.�-- -- ._.::.1*�.-- --------{t------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mt5po5ar *pgtem Conkrurtton Permit Permission is hereby granted to Construct( )Repair( )Upgrade(\ Abandon( ) System located at�b \��-�� 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. G Provided:Construction must be co plete within three years of the date of this Date: Approved by > Y i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated l , concerning the property located at meets all of the following criteria: (This failed system is connected 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 u There are no private wells within 150 feet of the proposed septic system 6- There is no increase in flow and/or change in use proposed 4,e There are no variances requested or needed. Cam✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Z- 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(14)feet above the maximum adjusted groundwater table elevation, 1 � Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation -D� +the MAX.High G.W.Adjustment.1 �6 = DIFFERENCE BETWEEN A and B SIGNED : DATE: Sti22 [Please Sketc -posed plan of stem on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert y - !, .: d 1 , � Y� II r AL0 "C`A T ION SEWAGE PERMIT NO. l o E (z Fee5+A �Aoue ✓w. 9?3- 4Sg VILLAGE INSTALLER'S NAME i ADDRESS Bowser B, oUi2 G I uc. I�l. �Af7.e�tJ t Gl-�. �455'. 07.64'S 0 UItDE R OR OWNER l .fit 5;• DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED Vw 14' w f Fss...�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7U �`F..............OF........�. '"'rr� ................................. Appliration for Disposal Works Tonstrudion Permit Application is hereby made for a Permit to Construct ( ) or Repair (X*5 an Individual Sewage Disposal System at: ................___•-__............__......-- -... ....... .............._.qAMQ .._�_�.........�...............•_......._..._..............--- tionAdess 1to. c ...Q am......................... L .0_ L --_.__.... ..&J.+ dchL��5 .............•----..... .......1. . ddre�s� Y .. y ---------------------- - Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ....... No. of persons................yp g ..................... p _....__..... Showers ( ) — Cafeteria ( ) 04 Other fixtures W Design Flow...........................5n.�......gallons per person per day. Total daily flow.................... ..._.._..........._gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.....,............ Total Length....... . Total leaching area.........._._ A. . ft. 3 Seepage Pit No------------I........ Diameter...�. ia�✓.... Depth below inlet............. Total leaching area..-�.5r-Ssq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by........................... .... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................ o ( ii�1 '�w � ctQ- riot �..Z. on of Soil..... ` ........................•5---t...- . -••L•t-Q--R.......... ... S. W.6........_.............•••--.........__.....--•-------•- Description *O�� -------------- ----------------------------------------------------------------------------•-•-........................---...-•-....•-••...-•------•- M . Nature of Repairs or Alter tions—Answer when applicable... ...4p i� 1�� ....COIIA.9L .....rAl e-rz...........Agreement: The undersigned agrees to install the afored ribed Individual4Seag Dispo 1 System in accordance with the provisions of TITLE 5 of the State Sanitary de—The undersither ees not to place the system in operation until a Certificate of Compliance ha issued by a boarth. -........ ................................. �.. ._ .. . .. --- D ApplicationApproved By....... • .. ... ....... ............................ ..• ---••--••---•-•-••---•-.-----. --- 1.I1� ... J1........ Date Application Disapproved e foil 'ng s asons:.............................••.............-•••.........................•-••••......•••-•.....--•-••••------- .........--•-•.................................f........................................_............._....------••-•••...........__.........--•-•..........................................._...._ Date PermitNo............................ .... Issued.-.........................._...... No: .... d Fsa.. .` THE COMMO WEALTH OF MASSACHUSETTS- BOAD OF HEALTH: ............. ..-.-....TZW :'............oF.............. -0.-.. ......_........................... ,Appliration for Disposal Works Tonstmrtilatt Ilumit Application is hereby made for a Permit to-Construct or Repair (4an Individual Sewage Disposal System at: ..............______......_..._-...... _..__....—------ .._....�..... Ad} ................................. ..l 012_t 10-___ Owaer . •-Ad a G................._.... ...._•-......................... ... Q. ...................... Installer Addreu Type of Buildin Size Lot................g _-•------_..Sq. feet .. Dwelling—No. of Bedrooms........................_ ..................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T of Building No. of persons............................ Showers a YPe g ............................ pe ( ) — Cafeteria ( ) a i d Other fixtures ...........................................•--••---•-••---.............-•---__•-•---...._........................_�.._... ._...................... WW Design Flow...........................5�.......gallons per person per day. Total daily flow. ... WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ i x Disposal Trench—No..................... Width..... ...........Total Length...... Total leaching area._.._...... , q. ft. 3 Seepage Pit No............I........ Diameter..... t.��'.... Depth below inlet.... ............. Total leaching area_... rKq. ft. Z Other Distribution box ( ) Dosing tank ( ) y.......................................................................... Percolation Test Results Performed b Date....................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f=, Test Pit No. 2................minutes per inch. Depth of Test Pit................... Depth to ground water........................ O Description of oil.... ..............` 1 O tJ ...l2 1!�iJca.l..i. .:...... ..... . V.��. 0�_C...... v.... - ..... � ...............•-•-•............_....-•--••... .................................................•-•._..........................---..._•••••...�...__... U Nature of,Repairs o Alter; —Answ when a licable.... _�>_...0?.XJ_>7 .. ! � 1.�,� r Rep IV e� .�Yam...... .... ....� ..�1. 1..... .'� .�..... �T ......! .....:3.........��:�.......... .�....--... Agreement: The undersigned agrees to install the aforede ribed Individual Slag Disposaal System in accordance with the provisions of TITLE 5 of the State Sanitary J e—The undersir agr snot to place the system in operation until a Certificate of Compliance issued by� e boar7- ge ....... . .......... ....._-=............_................. __ ...... ..f ...�.a... Application Approved By.. -- .�L..---�........................ !f......................... ...... . .rl. D. ----•--- Date Application Disapproved a foR 'ng r asons......................................................................................................... _.............................................................._.................._.._...-:---___..-•------............•••-•-•-•----••---•-•-.._.....---•-•--.....--•-••....________...._..__ Date PermitNo...........__....;.---....._. ..._ IssuecL..._...................._......__....___..... .,C1 Date THE COMMONWEALTH OF MASSACHUS S i -- BOARD OF HEALTH .............w.!"'I ...-.....-...OF.......! .?'K' .7 ............................... , farrtif irate of Toutplionrr THIS, IS TO CERTIFY hat a Individual Sewage Disposal System constructed ( ) or Repaired (a() by..._.....94 P)� ...0:. t-..�.1 6 C. ..-•---•........ ............._.................._......_........----__-................._......_.__...._ .......... at.....LJ�y"3evr_r ._�'__..:. ..U..!� e1 b <c l H HQ�.... h ............. .... 4�..has bn installed in accordance with the provisions of TI�.I,F,��?& State Sanitary Cod ribed in the ..application for Disposal Works Construction Permit No.............. .......... dated... ........ .... _.._.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S .OF........ 4�2/.� ,j - ............................. No .3.......Y/...... FzE....r�......v�:...... Disposal Varks Tonshvrtion 11rrmit Permission is hereby granted.... . ...... 6�... ic...--...•.........................................•--__ to Construct ( ) or ReL)mr ( an Individual Sewage Disposal System at No......1.Q.._.__ _.l.. .... ! f�''' .4 ... ... + :.._._ ! .�.��. ........................ ...... ��.. Street as shown on the ap/ication r Disposal Works Construction Permit No............... .: ated _...._._..._......._........._.......... ---•-•-•••....•--•-••_._.____..•-• . . ........................................................oard of Health DATE..........._.....-• ..................•........_..__......._ i FORM 1255 HOBBS d WARREN. INC.. PUBLISHERS I