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HomeMy WebLinkAbout0217 GREENWOOD AVENUE - Health 217 Greenwood Avenue Hyannis P A = 288 104 N i N b G 1 I f• e I rc a i h n 11-5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppficatiou for Misposai *pstem Construrtion vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.A 11 Gc4_(;QJLoi U®b dt V t Owner's Name,Address,and Tel.No. ti PaTEPL -a0CM4cu.& popaEl-j Assessor's Map/Parcel ;1 g g I 14)It 145 L<.)l&jS Low R!C> w t MA Installer's Name,Address,and Tel.No. ;5&IJ-Lf'Z-7 ,gg,7'1 Designer's Name,Address,and Tel.No. Ob"1vtD E GoTemkoes Lc f Type of Building: Dwelling No.of Bedrooms /V ° / Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) N gpd Design flow provided gpd 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 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signed Date Application Approved by Date S -3 6 - 13 Application Disapproved by Date for the following reasons Permit No. a 0 13 Date Issued 5 r 0 — f No. 0 _. ! Fee THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 1�± Zipplication for -Misposal 6pstrin Construction 3pPrm ` Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.A f? C QGWLU OOb Ptvt Owner's Name,Address,and Tel.No. {-1 Yt4N1�1 s 1>0 TES-k-iR.XJ4 G �L& gURa��1 Assessor's Map/Parcel 1 U O Installer's Name,Address,and Tel.No. 5 V� .t�.1?.,�gy, Designer's Name,Address,and Tel.No. CK06vct)E 40eS Type of Building: Dwelling No.of Bedrooms A �T Lot Size sq.ft. Garbage Grinder( ) �1 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /V gpd Design flow provided --Fgpd Plan Date Number of sheets Revision Date ,a 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 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date S -30--;M3 Application Approved by Date S - 3 d — /3 Application Disapproved by Date for the following reasons �q Permit No. c;0!I2 7 ^( l 5 Date Issued S�30 — f ---------------------------------------------------------------------------------------------------------------------------------- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(%�by at �q77 (GF4 tSr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. I-of 3` /'S dated 5 - 3 0 - 3 Installer Designer #bedrooms Approved design flow and The issuance o this permit shall not be construed as a guarantee that the system wil ation as design. Inspector No. ,W 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstrin (Construction 3permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at ") GJQki ya )If ..� 9D d.c 1 fN�eLx1X1I ,\ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit ^ Date — 3 d 3 Approved by I a J Town of Barnstable Barn �r .� Regulatory Services Department mmmeftaC j MRNSTASM MASS. I i63� Public Health Division _ 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0417 March 28, 2013 PETER & ROCHELLE BORDEN 145 WINSLOW ROAD IMPORTANT NOTICE NEWTON, MA 02468 Map & Parcel: 288- 104 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 217 Greenwood Ave, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. / PER ORDER OF THE OARD OF HEALTH mas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connectU,--tters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through ygur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: littp://www.town.bai-nstable.ma.us/cdbg (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PublicWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connectUtters Stewart Creek Sewer Connects\ TAILING LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is i anns MA 02601 May required for Hyannis y 5, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name VQ 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority y—�- �'� May 5, 2008 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 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. t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May 5, 2008 required for _ Y Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time. Leaching pit had never had more than 2'of standing water. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 I l5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is y required Hyannis MA 02601 May 5, 2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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: 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. t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is y required for y H annis MA 02601 May 5, 2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is required for Hyannis MA 02601 May 5, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 0 ® 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. t5insp.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is required for Hyannis MA 02601 May 5, 2008 every 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 (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-0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May required for Y y 5, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 71,250 gal. _ 9 ( Y 9 (gpd)): 97 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: 6 Months prior to inspection. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 15insp.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts M Title 5 Official Inspection Form R o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis required for MA 02601 May 5, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 9/10/93 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May required for Y y 5, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 1 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 61- Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May required for Y y 5, 2008 every 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.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is not in need of dumping at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 15insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is required for Hyannis MA 02601 May 5, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is required for Hyannis MA 02601 May 5, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: One 6x6 pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit was found empty at time of inspection, high staiin lines indicate pit had never had more than 2'of standing water. i t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is required for Hyannis MA 02601 May 5, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 ` �C\, Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May 5, 2008 required for _� _ Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 14 \ •. • . . , \ . \ \ 18 57 8 Water Service Greenwood Road Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Greenwood Road Property Address James D'Amico Owner Owner's Name information is Hyannis MA 02601 May 5, 2008 required for y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 30 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: Pond on opposite side of road is approximately 30 feet lower than grade at front yard. 15insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �f1HE 1p� Regulatory Services BARNSrABLE. : Thomas F. Geiler,Director MASK. 9$�E16 9. 0. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS r DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIMisclaimer Private Septic Inspections.DOC �,AR �� �vRCE[ COMMONWEALTH OF MASSACHUSETTSLaT z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION o� RECEIVED O,9M SV6 � 350 MAIN STREET A MAY 1 3 2004 WEST YARMOUTH,MA O 508-775 2800 TOWN U'r dHkNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Map 288 Par 104 Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner's Name: John Cummiskey Owner's Address: 217 Greenwood Avenue Hyannis,MA. 02601 Date of Inspection 04/22/04 Name of Inspector:(please print) James D. Sears Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 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 Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall su mit 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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 t e 5 Inspectton Form 6/15/2000 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:4 _ 1 have not found any infonnation 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: N/A 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. 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 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: I 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: 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 C. Further Evaluation is Required by the Board of Health:N/A 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ./ 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 pit]is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn.) 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: N/A To be considered a large system the system must service 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 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 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 nonmal 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)has been determined based on: Yes 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)] Title 5 Inspection Form 6/15/2000 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 FLOW CONDITIONS RESIDENTIAL,/ Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330 Number of current residents: 2 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonmation: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1993 PERMIT#93-454 Were sewage odors detected when arriving at the site(yes or no): NO OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 BUILDING SEWER(locate on site plan): ./ Depth below grade: 6" Materials of construction: Cast iron ./ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 7" Material of construction: ./ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 GALLONS Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 011 Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions detennined: AS BUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL,TANK&COVERS 7"BELOW GRADE,OUOT LET BAFFLE,NO SIGN OF OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: _ concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pupping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alann present(yes or no) Alann level: Alann in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D BOX IS 16"X 16"— 14"BELOW GRADE,ONE LINE IN,ONE LINE OUT. BOX IS CLEAN&SOLID NO SIGN OF OVER LOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 SOIL ABSORPTION SYSTEM(SAS): ,/ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000 GALLON PRE CAST PIT,PIT IS 40"BELOW GRADE WITH COVER AT 9". PIT IS WET LIKE NEW,NO STAIN LINE OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: �. Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) f Title 5 Inspection Form 6/15/2000 9 I Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cummmskey Date of Inspection: 04/22/04 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 public water supply enters the building. i /100r•Z.-I t L_ C 4/ Title 5 Inspection Form 6/15/2000 10 Page 1 l of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Greenwood Avenue Hyannis,MA. 02601 Owner: John Cumminskey Date of Inspection: 04/22/04 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 14 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: —� Observation 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: HAND DUGTEST HOLE 14' NO WATER,TEST HOLE 4' BELOW BOTTOM OF PIT. ij C y— 7 Title 5 Inspection Form 6i 15/2000 1 l