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HomeMy WebLinkAbout0025 FRESH HOLES ROAD - Health 25-27 Fresh Holes Road Hvannis P A= 292 150 o e � i TOWN OF BARNSTABLE LOCATION 2Jr t KrAfC SEWAGE # Z00LI - 3� VILLAGE 4 11106��S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. U l �S 52 T A,"(_ SEPTIC TANK CAPACITY I U U LEACHING FACU.=: (type) (size) , NO.OF BEDROOMS ►J_�pX Qn -a- i_BUILDER OR OWNER L_GZAc-o S:bea rcy-P �l» PERMTTDATE: ©'I 1177 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 �-3��- �� 4�,� �i oh��- .- _ � _ '© _ oo � Pl � — 2.� '��c � �- �� � ,, �'z- � ��� ��� � . .' OWN OF BARNSTABLE LOCATION� lr(etSI1Lk-t SEWAGE # VILLAGE Ci n I'1 S ASSESSOR'S MAP & LOT S SO . Y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ' s Feet mu Furnished by IA �� �S D p ° AA�l At �� 10 u .No. 21 Fee /W— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: kzL1___1 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ' 01paprication for Mqual bpgtem Construction Permit Application for a Permit to Construct( . )Repair(t, pgrade( )Abandon( ) O Complete System Xl udividual Components Location Address or Lot No. Ira — Z 1 v7ms�, Lakes Qj Owner's Name,Address and Tel.No. ( , Assessor's Map/Parcel f� 15D Crl�t L_cl2'aIr US Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Dou-Af_r e. k)be�S Po 3®X tsS*1 k-l�o,�nv��� OZroc Type of Building: (� Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title S of the_Envkonmental Code and not to place the system in operation until a Certifi- cate of Compliance has bFer ' this of H Signed 0A. ate -ZL-6 Application Approved by Date Application Disapproved for the following reasons Permit No. 6U,,) 3 2 ( Date Issued V ^� Z o Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: le— I Yes 'y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ' apprication=for Mood Opgtem Construction Vermtt Application for a Permit to Construct( )Repair(grade Abandon( ) El Complete System EX Ism ividual Components Location Address or Lot No. 2Cj - 2 7 o Owner's Name,Address and Tel.No. '(�eo �- Assessor's Map/Parcel /� C C,ZC,1 OS Installer's Name,Address,and Tel.No. ='6 -77`b <6 Designer's Name,Address and Tel.No. 1 c• p l S -1 r I—� �\C.r.r r1 5 r 0 2(o C Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan. Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil, r ; Nature of Repairs or Alterations(Answer when applicable) d ell J Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the • onmental Code and not to place the system in operation until a Certifi- cate-of Compliance has this of H l Signed Date —Z( of Application Approved by Date �- Application Disapproved for the following reasons Permit No. c200 U .� � ( Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS � —_I Y-- 04� Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( graded((i� Abandoned( )by )b s e at' — -.— c,&-K-r has been construe d i accordance with the provisions of Title's and the for Disposal System Construction Permit No. 70o 9, 3 7/ dated Installer' - . .._. . .:- Designer The issuance o.this p rmit shall not be construed as a guarantee that the syneflltnction designed. Date .Z u Inspector No. :3�CoL-1 -I Fee 0 d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS Misposar *pstem Construction Vertnit Permission is hereby granted to'Construct( )Repair( )Upgrade( A don( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. - Provided:Construction mus be compl ted within three years of the da of this e , r Date: 7� �� Approved by TOWN OF BARNSTABLE Itf- on LOCATION SEWAGE# Z OOL4 - 3-71 VILLAGE, cS ASSESSOR'S MAP&LOT - Z*L50 - -71 i INSTAL,LERt NAME&PHONE NO. SEPTIC TANK CAPACITY`_-t 0 O&.I - LEACHING FACILITY: (type) (size) NO.OF BEDROOMS -D B of on BUILDER OR OWNER_"ZQ 'y[ � PERMIT DATE:oZ 127 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 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRO DEPARTMENT OF ENVIRONME TAL ROTECTIOIN R d JUL 2 9 2004 Jyr TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART.A CERTIFICATION Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner's Name: GEORGE LAZARIS Owner's Address: 78 BORDER STREET SCITUATE,MA 02066 _ Date of Inspection: 7/15/04 ' Name of Inspector: (please print) JOHN GRACI,INC. . L!7 !P Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Y Telephone Number: 508-564-6813 FAX 508-564-7270 N) r*► 00 r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes X Conditiona asses _ Needs F Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/15/04 The.system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec ion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner s all submit the report to the'appropriate regional office of the DER.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION.D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED. RECOMMEND LOCATING FIELD WHEN D-BOX IS REPLACED AND DETERMINING CONDITION OF FIELD-NO ASBUILT OF FIELD WAS FILED WHEN LEACH FIELD WAS INSTALLED. ****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. Title 5 Tncnactinn Fnrm 6/1 50000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION.D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED.RECOMMEND LOCATING FIELD WHEN D-BOX IS REPLACED AND DETERMINING CONDITION OF FIELD-NO ASBUILT OF FIELD WAS FILED WHEN LEACH FIELD WAS INSTALLED. B. System Conditionally Passes: X One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or�break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed - distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a l Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a z i Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 9 . S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 5 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no):NO Water meter re adings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO (' Last date of occupancy: n/a Z=1 C1 I COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 7-12 YEARS Were sewage odors detected when arriving at the site(yes or no): NO r Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:H 10' 6" H 5' 7"W 5' 8"" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 6" How 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.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: n/a 1 leaching fields, number: LEACH FIELD n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a } Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): RECOMMEND LOCATING FIELD WHEN D-BOX IS REPLACED.NO ASBUILT OF FIELD ON FILE WITH BOH WHEN LEACH FIELD WAS INSTALLED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a e l 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS Date of Inspection: 7/15/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where Oic water supply enters the building. l L 0 2/I I nVo i � N to Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25/27 FRESH HOLES ROAD HYANNIS,MA 02601 Owner: GEORGE LAZARIS - Date of Inspection: 7/15/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. I 11 COMMONWEALTH OF MASSACHUSETTS T—I- EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS { DEPARTMENT OF ENVIRONMENTAL PROTECTION j t TITLE 5 OFFICIAL INSPECTION FORM—NOT,,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM FORM ' , PART.A�'.r �F CERTIFICATION yob i. Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 :DLCt Owner's Name: BOLOS TRUSTL ' � ' Owner's Address: 765 FALMOUTH RD HYANNIS 02601 s x Date of Inspection: 12/17/01 K Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS - ar * fi Mailing Address: P.O. BOX 2119 TEATICKET,MA.'02536 of BA,NSTABLE , TOWN TFi pEPT. HEAL Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT F I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is t , true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and ,, experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section'15.340 of Title 5(310 CMR 15.000)' The system: X Passesll ,ys _ Conditionally Pas s Needs Further luation by the Local Approving Authority Fails a: , Inspector's Signature: Date: 12/17/01 r � The system inspector shall submit ary of this inspection report to the Approving Authority(Board of Health or DEP)withm4 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 iP sent to the system owner and copies sent to the buyer, if applicable,and-the approving authority. Notes and Comments r I <s SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE � , , —E SYSTEM'S USEFUL LIFE. i T� F ****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 A Tiil,> S In-nnrPinn I nrm r'I moon' ;i i f Page 2 of 11 •', ' ,a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' • � CERTIFICATION(continued) �a Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601'' tif, � Owner: BOLOS TRUST (} Date of Inspection: 12/17/01 `� x. n Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section DY 11 A. System Passes: ', X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310=' `., . w, CMR 15.304 exist. Any failure criteria not evaluated are indicated below. � rc ��• rs Comments: , w SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THEA`� ��. SYSTEM'S USEFUL LIFE. q , r. 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. i Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain f. , n/a 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- r ` with a complying septic tank as approved by the Board of Health. 't . *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating x ; that the tank is less than 20 years old is available. t ND explain: n/a 4 n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed . pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): + _ broken pipe(s)are replaced _ obstruction is removed ,. _ distribution box is leveled or replaced ` n : ND explain: n/at M - n/a The system required pumpingimore 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): E'. ' sue:: _broken pipe(s)are replaced _obstruction'is removed r�f ND explain: n/a ' t Page 3 of I Itti#, a' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a ; PART A a CERTIFICATION(continued) ~ Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 ' Owner: BOLOS TRUST Date of Inspection: 12/17/01 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. f 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system_ rs not functioningin a manner which will protect public health safety and the environment: * ' P P , Y ��•, ;���. _ Cesspool or privy is within 50 feet of a surface water y _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Y` c , v 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)• 100 feet of a surface water t- hin w and the SAS is it 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. *Fc' 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 Y P .r.. _ Y yy supply well". Method used to determine distance n/a , PP Y n t: a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and <: a volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammoniac a 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 fo this"form. f i M. 3. Other: n/a V.? s: °ASP Page 4 of 1144 �� �yy OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � . PART A F O CERTIFICATION(continued) Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 Owner: BOLOS TRUST Date of Inspection: 12/17/01 D. System Failure Criteria applicable to all systems: � �4t You must,indicate"yes"or"no"to each of the following for alLinspections: ` Yes No X Backup of sewage into facility or stem component due to overloaded or clogged SAS or cesspool - p g h' Y P gg p - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool - X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ` - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times' �r ' pumped nLa. - X Any portion of the SAS,cesspool or privy is below high ground water elevation. 3 - X Any portion of cesspoofor privy is within 100 feet of a surface water supply or tributary to a surface water supply 1. �u it - X Any portion of a cesspool orxprivy,is within a Zone 1 of a public well. {, - X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4. - X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP � 5 certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free = i = from pollution from that�:facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or � t ':; less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] k �` i R,; (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 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. , k f t . 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 gpdu ` You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - X the system is within 400 feet of a surface drinking water supply - X the system is within 200 feet of a tributary to a surface drinking water supply : - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public watWsupply well If you have answered"yes'!to any question in Section E the system is considered a significant threat,or answered , t' "yes" in section D about;the large sysleni has failed.The owner or operator;of any large system consid@red a significant thf@at 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. L, ' � ra v r Page 5'of 11 4,r t '3x k , -• OFFICIAL INSPECTION FORM-NOT FORNOLUNTARY ASSESSMENTS £n SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B CHECKLIST:, " M. Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 , Owner: BOLOS TRUST Date of Inspection: 12/17/01 i Check if the following have been done. You must indicate"yes"or"no"as to each of the following: , Yes No 4 t^ f- X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? fi { a � � X _ Has the system received normal flows in the previous two week period? 14J. X Have large volumes of water been introduced to the system recently,or as part of this inspection? X Were as built plans of the system obtained and examined? If.the were not available note as N/A) `� fit' P Y ( Y �X! X _ Was the facility or dwelling inspected for signs of sewage backup? � ' X _ Was the site inspected for signs of break out'? k, X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? r r; X _ Was the facility owner(and occupants if different from owner)provided with information on the proper mamtenance� �qa of subsurface sewage disposal systems? r' ij! The size and location of the Soil Absorption System(SAS)on the site has been determined based on: �. Yes no X _ Existing information. For'example,a plan at the Board of Health. 'Z. r X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] � h.Y a kl-,r r i�a P Ri. ' y Page 6 of 11 x v s ate, OFFICIAL INSPE"CTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .F ' PART C a <.. SYSTEM INFORMATION Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 Owner: BOLOS TRUST ,, • Date of Inspection: 12/17/01 .FLOW CONDITIONS RESIDENTIAL ^f 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 ` _ ,ia } Number of current residents:4 j � Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO ' "3 "MMI r Seasonal use: (yes or no): NO a. Water meter readings, if available(last 2 years usage(gpd)): n/a , Sump pump(yes or no): NO " Last date of occupancy: n/aah {, COMMERCIALANDUSTRIAL ' Type of establishment: n/a s Design flow(based on 310 CM 15.203):•n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO meµ$ Industrial waste holding tank present(Yes or no): NO -�- Non-sanitary waste discharged to tA6 Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION :z' Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO y ,R If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool ; _Overflow cesspool f _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if an _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) } _Tight tank Attach a copy of the DEEP approvals Other(describe): n/a ' Approximate age of all components','date=installed(if known)and source of information; ' APPROXIMATELY 5- 10 YEARS OLD. Were sewage odors detected when arriving at the site(yes or no): NO ; 1w { �_. Page 7 of 11 { OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART C *� ` SYSTEM INFORMATION(continued) ` " b k'd •t � " Property Address: 25-27 FRE SH HOLES HYANNIS MA 02601 Owner: BOLOS TRUST " ffi'• Date of Inspection: 12/17/01 ' BUILDING SEWER(locate on site plan) Depth below grade:30 p Materials of construction:_cast iron X40 PVC other(explain): n/a .r Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) p� Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a g g Y p (Y ) ( copy ) If tank is metal list age: n/a Is age confirmed b a Certificate of Compliance es or no : NO attach a co of certificate Dimensions: 150OG L 10 6 H 5 7 W 5,.'8 Sludge depth: 2" Distance from top of sludge to bottom of outlet.tee or baffle:32" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 6" n 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.): �; � SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.' .. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. GREASE TRAP:_(locate on site plan), . Depth below grade: n/a Material of construction: concrete metal fiberglass_polyethylene other(explain): n/a Dimensions: n/a � t Scum thickness: n/a �3 Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a " Date of last pumping: n/a `* A . Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related r, to outlet invert,evidence of leakage,etc.):" n/a x �k�r page 10-of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C ` SYSTEM INFORMATION(continued) Property Address: 25-27 FRESH HOLES H,YANNIS,MA 026014 - Owner: BOLOS TRUST Date of Inspection: 12/17/01 SKETCH OF SEWAGE DISPOSAL SYSTEM �Lx Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. i# a M1 Locate all wells within 100 feet. Locate where public water supply enters the.,buildin . PP Y g At �j� Sz 41, K� " { G p O , � . t d ' QA PM i7. �IT ; Vas . k; t a F _ z I� f Page I I of I I `# � .. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS +7� r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + ' PART Cr t SYSTEM INFORMATION(continued) ' Property Address: 25-27 FRESH HOLES HYANNIS,MA 02601 Vie' y Owner: BOLOS TRUST Inspection: 12/17/01 ..... , Date of Inspec ka SITE EXAM E�G t _Slope -`� _Surface watery Check cellar Shallow wells KL. Estimated depth to ground water 12+feet t� Please indicate(check)all methods used to determine the high ground water elevation: " NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a t " YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) � . YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: $ � r�air is GROUNDWATER DETERMINED BY AUGER-NO WATER AT 12+FT. m a 3 . t 1 , a x �F.