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0027 HAMDEN CIRCLE - Health
27 Hamden Circle Hyannis A = 291 - 188 i i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L,.-it does not give you permission to opera e. ou must first obtain the necessary signatures on this format 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S: Z cf - �' BUSINESS YOUR HOME ADDRESS: ' TELEPHONE # Home Telephone Number. O E-MA I L: E 1 N OR : (/� NAME OF CORPORATION: i NAME OF-NEW BUSINESS ( r; %v TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO / ADDRESS Or BUSINESS �' f V�, AP/PARCEL NUMBER / AV (Assessing) . When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Tdwn of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally op e yo iM b-tv! ess in this town. 1. BUILDING COMMISSIO R'S QQFFICE This individual has b infor e of any permit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION RULES ANO REGULATIONS. FAILURE TO Authorized Si n ture** COl'-.1P ..Y MAY RESULT IN FINES, COMMENTS: ��w+l .v/l�� o^L 2. BOARD OF HEALTH l This individual has been i ermit re ement at pertain to this type of business. a MUSS COMPLY WITH AIL Authorized Signature** HAZARDOUS MATERIALS R�,Q! 1( i COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: „2 ,� �/,� Ce6L'7,�1,✓„✓,"zT INVENTORY MAILING ADDRESS: TOTAL AMOUNT. TELEPHONE NUMBER: 5-0�%/ 5-1�3 9Z CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: - A4r— INFORMATION / RECOMMENDATIONS: Fire District: r= Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides herbicides, roences ❑ NEW ❑ USED (insecticides, biid dtiid ) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde`, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents .p Bug and tar removers �— Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials �� PR14rR ENVIRONMENTAL SERVICES 95 River Rd, Mashpee, MA 02649 1 508-296-LEAD(5323) cr"? LETTER OF FULL INITIAL LEAD INSPECTION COMPLIANCE ��- r Marly Cardoso 64 Compass Cir Hyannis, MA 02601 CA Dear Marly Cardoso:. This letter is to certify that I inspected your property located at 27 Hamden Cir,Unit NONE,and relevant interior and exterior common areas, in the City/Town of Hyannis for dangerous level's of lead according to 105 CMR 460.730 of the.Regulations for Lead Poisoning Prevention and Control, and determined that there were no violations of the Lead Law, Massachusetts General Laws,Chapter 111,section 197. The inspection was conducted on 11/18/14. ® I also certify that I observed no evidence or signs that unauthorized deleading activities may have occurred in this unit or in its associated common areas. Please be advised that Massachusetts law requires that only certain residential surfaces be free of lead paint. Thus, this letter does not mean that your property contains no lead paint. The residential premises or dwelling unit and relevant common areas shall remain in compliance with the requirements of the Lead Laws referenced above only as long as there continues to be no peeling, chipping or flaking lead paint or other accessible leaded materials, as long as coverings and/or encapsulants forming an effective barrier over such paint or other leaded materials remain in place,and as long as surfaces reversed to correct lead hazards remain reversed and securely in place The law grants you a 30-day maintenance period to repair deteriorated lead paint or detached coverings over such paint, and to clean up, during which time this Letter remains valid. The initial inspection report indicates which surfaces, if any, contain a dangerous level of lead, as well as those surfaces, if any,that were covered upon initial inspection. The CLPPP authorized serial number for this Letter of Full Initial Lead Inspection Compliance is 45463985112114-27. This number is tracked and unique to this address and unit. DO NOT LOSE THESE DOCUMENTS. If the documents are lost you will be required to have additional private inspector services that may cost you significant amounts of money. This Letter of Full Initial Lead Inspection Compliance is only for the address and unit number noted above. If you change the street address, unit/apartment number or any other identifying information pertaining to the residential premises referred to in this Letter of Full Initial Lead Inspection Compliance, this Compliance Letter may be considered null and void by the Department of Public Health and/or a municipal health office. Do not alter this document in any way. Altering this document is fraudulent and may endanger the health and safety of a child which may result in significant legal consequences. In addition to any potential civil liability which may arise as the result of the alteration of this Letter of Compliance, the Massachusetts Department of Public Health's Childhood Lead Poisoning Prevention program may seek criminal prosecution of any person who alters this document after it is originally issued. Sincerely, Paula 3985 11/21/14 Inspect r License# Date Questions?Call the Department of Public Health at 1-800-532-9571. DO NOT LOSE THESE DOCUMENTS LOF1C—rev01/12 Page i of 1 PRIPage 1 of 17 ENVIRONMENTAL SERVICES 95 River Rd, Mashpee, MA 02649 1 508-296-LEAD(5323) Lead inspection i Risk Assessment Report St.# Street Name Street Type Unit. 7 AMDEN 1 IR NON city Zip Code Y A N N I S 02601 Number of Rooms.in Unit s Owner Name: Marcy Cardoso Property Type: Owner Address: 64 Compass Cir,Hyannis,MA 02601 Single Family M Contact Information: Multi Family _#Units Condominium_#Units Client Name(if different from owner): Gerald Cardosa 508-577-7422 Day Care—Other: Client Address: Key: Lead Column Key: Delead/IC Method Column Laundry in Basement? Y r No Cov Covered CAP Capped SCR Scraped Finished Space in Basement? Yes o VB vinyl Baseboard cov Covered DIP Dipped MET Metal ENC Encapsulated REM Removed VR Vinyl Rep.Window MI Made Intact REP Replaced Testing Method Used: MR Metal Rep.Window PRE Prepared for Enc REV Reversed Na2S Exp.Date NA Nat Accessible VR/MR Vinyi/Metai Rep Window INT Intact NC No Coating SFR Storm Frame Removed X-Ray Fluorescence Tile Tde(testing suggested) Component Does not Exist Model LPA Serial# 2441 DC Dropped ceding Comment$I Notes Floor# (this is the level within the building of unit being inspected) Floor# Property Diagram!Unit Labels C C b B D B --- Rm4 Bath Kitchen i i ►al Rm1 _................ -..--•--------- Rm3 Rm2 Start Start i A(Street Side) A(Street Side A(Street Side) Pb(lead)equal to or greater than 1.0 mg/cm2 with x-ray fluorescence or positive with Na2S is Dangerous. XRF Calibration Recorded in Log Book ✓ -Check off when complete Address verified through USPS ✓ -Check off when complete Research on Lead-Related History for Address 77 -Check off when completE www.state.ma.us/dph/ciopn or 800-532-9571 Inspector Name: Paula Prior Lic#3985 Signature— Date 11/18/14 LURA Rev 9/11 r Page 2 of 17 ADDRESS: 27 Hamden Cir Apt# City Hyannis INSPECTION HISTORY INTERIM CONTROL Determination Risk Assessment y Insp.Name: Lie# I I I I I I y RA.Name: Uc# N Signature N Signature Lead Hazards? U ent Pb.Hazards? Comprehensive Dust Taken for Risk Initial Inspection Y Insp.Name: Paula Prior Litt 3985 Assessment P RA.Name: Lie# 1 1 I 8 114, N Signature F Signature Lead Hazards? Visual Portion of Comp Initial Reinspection for p R.A.Name: Lint w/Partial PCAD y Insp.Name: Lic# Interim Control_ F Signature N Signature Lead Hazards? Dust Taken for Risk P R.A.Name: Lid Assessment Reinsp. Addendum(add-on to Initial Inspection) y Insp.Name: Lic# F Signature N Signature Visual Portion of Reinspection for P RA.Name: Lie# Lead Hazards? Interim Control Addendum as Full F Signature Insp.(Lost Does) y Insp.Name: Litt Signature Dust Taken for Risk P RA Name: Lid N Assessment Reinsp. Lead xazards? F Signature Walk Through for Insp.Name: LIC# Ed/Consultation Risk Assessment Signature Recertification y RA.Name: Lid REINSPECTION HISTORY I I N Signature Visual Portion of — Insp.Name: Lie# Urgent Pb.Hazards? Reocc.Reinspection Signature Dust Taken for RA P Recertification R.A.Name: Lit# Visual Portion of ® Insp.Name: Ut#t F Signature Reocc.Reinspection aSignature POST COMPLIANCE ASSESSMENT DETERMINATIONS PCAD Dust Taken for ® Insp.Name: Uc# EN Insp.Name: Lid Reocc.Reinspection oSignature Lead Hazards'► Signature Dust Taken for Insp.Name: Litt p�l Inspection Reocc.Reinspection P g w Insp.Name: Lid FSignatureSignature Visual Portion of P Insp.Name. Lic# Lead Hazards? Final Reinspection Visual Portion of P Insp.Name: LidF Signature PCAD Reinspection F Signature Visual Portion of P Insp.Name: UC# Final Reinspection Dust Taken for P Insp.Name: UC# F Signature PCAD Reinspection F Signature Dust Taken for Final ® Insp.Name: UC# Reinsp.(No Reocc) Dust Taken for F Signature PCAD Reinspection P Insp.Name: Lit# F Signature Dust Taken for Final ® Insp.Name: Lid Reinsp.(No Reocc) aSignature r Page 3 of 17 ADDRESS: 27 Hamden Cir Apt# City Hyannis REOCCUPANCY CERTIFICATE HISTORY COMPLIANCE HISTORY(CONT.) Certificate of Certificate of Reoccupancy Insp.Name: Lid Maintained Insp.Name: Lid Compliance Signature Signature Only after High/Mod Risk No Work=No Dust (#rooms rule) Work=7 Dust Certificate of Certificate of Reoccupancy Insp.Name: Lid Restored Insp.Name: Lid Compliance Signature Signature Only after High/Mod Risk Dust wipes and auth. (#rooms rule) people Certificate of Certificate of Reoccupancy Insp.Name: Lid Maintained Insp Name: Litt Compliance Signature Signature Only after High/Mod Risk No Work=No Dust (#rooms rule) Work=7 Dust COMPLIANCE HISTORY Certificate of Letter of Full Initial Restored Compliance Paula Prior 3985 Insp.Name: Lid p Insp.Name: Lic# Compliance 1111 118.111 4 Signature Signature No prior history/ Dust wipes and auth. No signs of UD people Letter of interim OTHER HISTORY:WAIVERSIUD/EPA RRP Control Insp.Name: Lit:# Ap proved Signature CLPPP Waiver CLPPP Insp.Name: Lid No prior Comp. Signature Expires in 1 yr. Attach to Comp g Does Recertification of Interim Control Insp.Name: Lid Approved Signature CLPPP Waiver CLPPP Insp.Name: Lid Expires 2 yrs from original Interim Signature Control Attach to Comp Does Letter of Full UD/DES Visual Deleading Insp.Name: Lid Reinspection Compliance Ins Name: LiC# p p• Signature F Signature Dust wipes if No No LOC Issued Reoce' UD/DES Visual Reinspection p Insp.Name: Lid Certificate of Maintained Insp.Name: LidF Signature Compliance Signature No LOC Issued UD/DES Dust No Work No Dust Taken Insp.Name: Lid =7 Dust p p' F Signature Certificate of No LOC Issued Restored Insp.Name: Lid Compliance UD/DES Dust Signature Take° p Insp.Name: Litt Dust wipes and auth. people F Signature No LOC Issued Page 4 of 17 EXPLANATION OF LEAD INSPECTION/RISK ASSESSMENT REPORT FORM COLUMNS This page provides general information needed to understand the lead inspection/risk assessment report.However,you should speak with the inspector/risk assessor before you start to do any work on your home. SIDE Refers to A,B,C,or D side of the building or room. See the diagram on the cover sheet. The"A side of the building or room is the side facing the street that gives the property its address(usually,it is the front of the building).Keeping your back to this street,from the"A"side move clockwise to the"B"side on your left,the"C" side opposite you,and the"D"side to the right. Numbering is from left to right. LOCATION/ Refers to the building component(s)being tested. Some surfaces may be made up of more than one part.For SURFACE example,"Baseboard"may refer to four separate pieces of wood(one on each wall),but is still considered one surface. LEAD The actual lead result.Each surface tested must have a result recorded in the"Lead"column. • A number shows that the surface was tested with an XRF analyzer.A number(or average number)equal to or greater than 1.0 mg/cmz is a dangerous level of lead. • A"pos"or"neg"shows that the surface was tested with sodium sulfide."Pos"means that there is a dangerous level of lead. • "N/A"means that the inspector was not able to test the surface.Unless the owner can get a sample to test,the inspector must assume the surface contains lead and,require it to be deleaded,if necessary. • "MET'or"MR"means that a metal surface was not tested and only needs to be intact,even if it is a leaded surface. However,metal handrails,metal window sills,and metal railing caps,need to be deleaded if they test equal to or greater than 1.0 mg/cm2,or is marked"N/A." • � �, " For key to abbreviations like"COV' " «, VB , VR» 'or MR»,«NC , Tile» «,"DC", the cover page. • When a component box is slashed and there are test results above and below the diagonal line,the result on the "bottom"represents results below 5 ft.and the"top"result indicates the test result above 5 ft. TYPE OF Not all lead paint must be deleaded.This column tells you IF and WHY a surface needs deleading.The deleading HAZARD standards below may not apply for Interim Controls.Speak to your risk assessor for more information. • "M/I"circled means that the surface is a moveable/impacted surface and must be deleaded in its entirety. • "SF"circled indicates that there is a storm frame present which requires the blind stop and exterior sill be deleaded as interior moveable/impacted surfaces. • "A/M"circled means that the surface is"accessible mouthable"and must be deleaded to a minimum of five feet high,four inches in from the edge or corner. • "L"circled means that the surface is loose and must,at minimum,be made intact. • If more than one choice is circled,the rules for deleading may change depending upon what method of deleading you choose. Speak to the inspector for more information. • "N/A"means the inspector was unable to determine if the surface was a lead hazard.The person doing the deleading must check this surface and follow all the rules for deleading. Speak to the inspector for more information. • If nothing is circled in the column,then it is likely the surface does not need deleading.Speak to the inspector for more information. Remember,this does not mean the entire surface is lead free,it just does not require deleading in its current condition. URG HAZ? This column is only completed during a risk assessment.A risk assessment is an evaluation of a home's suitability for Interim Control. Only a licensed risk assessor can do a risk assessment,not all inspectors are risk assessors. If"Y"is circled,then this surface is considered an"Urgent Lead Hazard"and some type of deleading work is required to qualify for Interim Control. IC DATE The date the licensed risk assessor determines the surface meets the standards for Interim Control. IC METH The deleading method or structural repair done to qualify the surface for Interim Control.Refer to the deleading codes key on the cover page. DELEAD The date that the lead inspector reinspects the surface and finds that it has been successfully brought back into DATE - compliance. DELEAD The method used to bring a surface into full compliance.Refer to codes in the Key on the cover page of the PCAD METH EXCLUDED The amount of loose paint on a surface as measured by the lead inspector."N/A"means that the inspector was not SURFACES able to measure the loose paint,but has determined it is more than the cut-off for moderate risk making intact. LIRA Exp.8/08 Page 5 of 17 Paula Prior I/R-3985 2L o 11118/14 Inspector(print) Uc# Signature Date Risk Assessor(print) Uc# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis ROOM# / SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAr, DATE METH DATE METH SURFACE HAZARD HAZi DATE METH DATE METH Up Wails AIM L N/A y Window SilC D, MA AIM L NIA y Low Walls A/M L NIA y B Win Apron ,0..1 A/M L N/A y Baseboards A/M L N/A Y C Win Casing AIM L NIA y Chair Rai AIM L N/A y D Header Stop MA A/M L NIA y CD Radiator 00 A/M L N/A y Int Stops (; MA A/M L NIA y CD Floor 0. i AIM L N/A y Win Int Sash MA A/M L N/A y am Ceiling p ; AIM L NIA y 2 Exterior SRI M/1 SF L NIA y Door V A/M L MAI y 1 3 Part Bead V MA L N/A y C D Door Casing A/M L N/A y ¢ Blind Stop MII SF L WA y 12 Door Jamb Q AIM L N/A y Win Ext Sash ` M/I L N/A y 3 4 A/M L N/A y A Window Sill MA AIM L N/A y A Poor � A/M L N/A y B Win Apron A/M L N/A y C D Door Casing A/M L N/A y C Win Casing AIM L N/A y 12 Door Jamb a A/M L N/A y D Header Stop M/I AIM L N/A y 3 4 Threshold A/M L N/A y Int Stops W AIM L N/A y A B Door AIM L N/A y 1 Win Int Sash MA A/M L N/A y C D Door Casing AIM L N/A y 2 Exterior Sill MA SF L NIA y 2 Door Jamb AIM L N/A y 3 Part Bead Mil L N/A Y 3 4 Threshold A/M L NIA y ¢ Blind Stop MA SF L N/A y AB Door j A/M L NIA y Win Ext Sash M/I l N/A y C D Door Casing A/M L NIA y A Window Sill M/I A/M l N/A y 12 Door Jamb A/M L NIA y B Win Apron AIM L N/A y 34 Threshold A/M L N/A y C Win Casing AIM L N/A y A Closet Door A/M L WA y D Header Stop MA A/M L N/A y ® CA Casing �.j AIM L N/A y Int Stops I . MII AIM L NIA y C Closet Jamb i A/M L N/A y 1 Win Int Sash M/I AIM L NIA y D Closet Walls r} AIM L NIA y 2 Exterior Sill Mil SF L N/A y Cl Baseboard A/M L NIA y 3 Part Bead M/I L N/A y 1 Closet Pole A/M L N/A y ¢ Blind Stop M/I SF L N/A y 2 Closet Shelf A/M L N/A y Win Ext Sash M/1 L N/A y 3 Cl Supports N.v AIM L N/A y A B Fireplace (� AIM L N/A Y ¢ Closet Floor A/M L N/A y C ManteVIISt 0 j AAA L N/A Y Closet Ceilingtj I A/M L N/Al y I Win Above 5' A/M L N/A y COMMENTS/STRUCTURAL DEFECTS: MW Ceiling Moldind A/M L N/A Y A/M L NIA Y AIM L NIA Y AIM L N/A Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact cingly b a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SQ.IN. DATE METHOD MORE THAN 288 SQ.IN. DATE METHOD rage a yr -r 1 Paula Prior IIR-3985 Zito— 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis ROOM# )� SIDE LOCATION! LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD AZI DATE METH DATE METH SURFACE HAZARD HAZ1 DATE METH DATE METH Up Walls p AIM L N/A y A Window Sill j MA A/M L N/A y Low Walls AIM L N/A y B Win Apron AIM L N/A y Baseboards AIM L N/A y C Win Casing AIM L N/A y o Chair Rail A/M L N/A y D Header Stop Nf M/I AAM L N/A y D Radiator J A/M L NIA y Int Stops LL M/1 AIM L N/A y Floor AIM L N/A y 1 Win Int Sash 0,0 M/I AIM L N/A y Ceiling A/M L N/A y 2 Exterior Sill Ajtl MA SF L N/A y A B Door yj A/M L NIA1 y 3 Part Bead IVU M/I L NIA y D Door Casing AIM L NIA y 4 Blind Stop MA SF L N/A y 2 Door Jamb n AIM L N/A y Win Ext Sash JEMA L N/A y 34 Threshold AIM L NIA y A Window Sill M/1 AIM L N/A y A B Door AIM L N/A y B Win Apron j AIM L NIA y C t Door Casing A M L N/A y C Win Casing AIM L N/A y 12 Door Jamb A/M L N/A y D Header Stop MA AIM L NIA y 3 4 Threshold AIM L NIA y Int Stops M/f AIM L N/A y A B Door AIM L N/A y I Win Int Sash MA A/M L NIA y C D Door Casing A/M L N/A y 2 Exterior Sill MA SF L N/A y 12 Door Jamb AIM L N/A y 3 Part Bead MA L N/A y 3 4 Threshold AIM L N/A y 4 Blind Stop MA SF L NIA y A B Door A/M L N/A y Win Ext Sash M/I L N/A y C D Door-Casing AIM L N/A y A Window Sill M/I A/M L NIA y 12 Door Jamb AIM L N/A y B Win Apron A/M L N/A y 3 4 Threshold AIM L N/A y C Win Casing A/M L NIA y A Closet Door AIM L N/A y D Header Stop MA AIM L N/A y B Cl Casing AIM L NIA y Int Stole M/I A/M L NIA y C Closet Jamb AIM L NIA y 1 Win Int Sash M/1 AIM L NIA y Closet Walls ���- A/M L NIA y 2 Exterior Sill MA SF L N/A y Cf Baseboard AIM L N/A y 3 Part Bead M/I L NIA y Closet Pole NC, AIM L N/A y 4 Blind Stop MA SF L NIA y 2 Closet Shelf G AIM L NIA y lWin Ext Sash MA L N/A y UCI Supports Rf^ AIM L N/A y AB Fireplace A/M L N/A Y Closet Floor v A/M L N/A y C D Mantel A/M L NIA Y Closet Ceiling IV.A I AAd L N/A y p Win Above 5' AIM L N/A y COMMENTS/STRUCTURAL DEFECTS: Ceiling Moldirq AIM L N/A Y AIM L N/A Y A/M L N/A Y A/M L N/A Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact ohly b a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SO.IN. DATE METHOD MORE THAN 288 SQ.IN. DATE METHOD Paige 7 of 17 Paula Prior I/R-3985 �,/��! G'"( 11/16/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address or Property: 27 Hamden Cir Apt.# City Hyannis ROOM# SIDE LOCATION/ LEAD TYPE OF UR ZARD H IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD DATE METH DATE METH SURFACE HAZARD AZ DATE METH DATE METH Up Walls i� AIM L N/A y A Window Sill —Q M/I AIM L NIA y Low Walls %h A/M L N/A y B Win Apron AIM L N/A Y Goo Baseboards 6.1 AIM L N/A y C Win Casing �,J AIM L N/A y AB CD Chair Rail A/M L NIA y D Header Stop 1. M/I AIM L N/A y Radiator AIM L WA y Int Stops V Mil A/M L NIA y Floor A/M L WA y Win Int Sash ,) M11 A/M L NIA y Ceamg � A/M L N/A y Exterior Sill , M/I SF L NIA y A B Door A/M L NIA y Part Bead r M/I L N/A y D Door Casing _ AIM L NIA y 4 Blind Stop M/l SF L N/A y 2 Door Jamb AIM L N/A y Win Ext Sash r M/l L NIA y 34 Threshold A/M L N/A y A Window Sill Q ( M/I AIM L N/A y A B Door A/M L N/A y @ Win Apron ,� A/M L N/A y be Door Casing —� � A/M L N/A y C Win Casing 0. 1 AIM N/A y 1 @ Door Jamb A/M L N/A y D Header Stop V M/I AIM L NIA y 3 4 Threshold on.jo A/M L N/A y Int Stops M/I A/M L N/A y A B Door AIM L N/A y 1 Win Int Sash 1 0 M/I A/M L NIA y C D Door Casing A/M L NIA Y 2 Exterior Sill NL M/I SF L N/A y }2 Door Jamb A/M L N/A y 3 Part Bead ' M/I L N/A y 34 Threshold A/M L NIA y 4 Blind Stop WI SF L N/A y AB Door AIM L N/A y Win Ext Sash M/I L N/A y C D Door Casing AIM L N/A y A Window Sill MA AIM L N/A y 12 Door Jamb AIM L N/A Y B Win Apron A/M L N/A y 34 Threshold A/M L N/A y C Win Casing A/M L N/A y A Closet Door 0 A/M L N/A y D Header Stop Mil AIM L N/A Y B Cl Casing — A/M L N/A y Int Stops M/I A/M L NIA y (J Closet Jamb A/M L N/A y 1 Win Int Sash M/I A/M L WA v Y D Closet Walls 1 A/M L NIA Y 2 Exterior Sill M/I SF L N/A Y Cl Baseboard ARuI L WA Y 3 Part Bead W L NIA y I Closet Pole ° A/M L NIA y 4 Btihd Stop M/I SF L N/A y 2 Closet Shelf A/M L N/A y Win Ext Sash M/1 L N/A y 3 CI Supports A/M L N/A y A B Fireplace A/M L N/A Y 4 Closet Floor V AIM L NIA Y CD Mantel A/M L N/A Y Closet Ceiling IVk A/M L N/A y AUD Win Above 5' AIM L N/A y I OMMENTS/STRUCTURAL DEFECTS: Ceiling Moldi AIM L N/A y A/M L WA Y AN N/A Y AIM L N/A Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDEJ LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SQ.IN. DATE METHOD MORE THAN 288 SQ.IN. DATE METHOD Page 8 of 17 Paula Prior I/R-3985 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Pro 27 Hamden Cir Apt.# City: Hyannis ROOM# SIDE LOCA ION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD HAZ DATE METH DATE METH AR cly Up Walls ;.{ A/M L N/A y A Window Sill oa MR.A/M L N/A y Low Walls AIM L N/A y U Win Apron -p A/M L WA y Baseboards AIM L N/A y C Win Casing AIM L NIA y Chair Rail AIM L NIA y D Header Stop Mn A/M L N/A y A Radiator p AIM L N/A y Int Stops " MA AIM L NIA y Floor A/M L WA y f Win Int Sash MR AIM L N/A y Calling p A/M L NIA y 2 Exterior Sill Lill SF L N/A y B Door Q AIM L NIA y 3 Part Bead MA L NIA y C D Door Casing .�. AIM L N/A y 4 Blind Stop MA SF L NIA y 12 Door Jamb AIM L N/A y Win Ext Sash MR L NIA Y 3 4 Threshold AIM L N/Al y A Window Sill MR AIM L NIA y A B Door p P AIM L N/A y B Win Apron Q AIM L N/A y Door Casing j. A/M L N/A y Win Casing AIM L NIA y 12 Door Jamb A/M L N/A y D Header Stop ' MR A/M L WA y 3 4 Threshold 0.0 AIM L WA y Int Stops tj j/ MR AIM L WA y A B Door AIM L N/A y 1 Win Int Sash MA A/M L WA y C D Door Casing A/M L NIA y 2 Exterior SRI (/ MA SF L NIA y 12 Door Jamb A/M L NIA y 3 Part Bead V Mn L N/A y 3 4 Threshold A/M L NIA y 4 Blind Stop MR SF L WA y A B Door A/M L N/A y Win Ext Sash LY Mil L WA y C D Door Casing AIM L NIA y A Window Sill W A/M L N/A y 12 Door Jamb A/M L N/A y B Win Apron A/M L N/A y 3 4 Threshold AJM L WA y C Win Casing AIM L N/A y A Closet Door A/M L WA y D Header Stop MR AIM L N/A y B Cl Casing _ A/M L N/A y Int Stops MR A/M L N/A y C Closet Jamb AIM L N/A y 1 Win Int Sash MR AIM L NIA y D Closet Walls 4j A/M L N/A y 2 Exterior Sill MR SF L N/A y Cl Baseboard AIM L N/A y 3 Part Bead MR L NIA y 1 Closet Pole ITC, AIM L N/A y 4 Blind Stop MA SF L NIA y 2 Closet Shelf V AIM L N/A y Win Ext Sash 11 L N/A y 3 CI Supports r AIM L N/A y AB Fireplace AJM L N1A Y 4 Closet Floor AIM L N/A y C D Mantel A/M L N/A Y AB Closet Ceiling I AIM L N/Al y I I I p Win Above 5' AJM L N/A y COMMENTS STRUCTURAL DEFECTS: Calling Mold! AJM L N/A Y AIM L N/A I Y AJM L N/A Y AIM L NIA Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only by a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 298 SO.IN. DATE METHOD MORE THAN 288 SO.IN. DATE METHOD r Page 9 of 17 Paula Prior I/R-3985 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis BATHROOM# SIDE LOCATION/ LEAD TYPE OF URC4 IC I IC DELEAD DELEAD SIDE LOCATION/ LEAD I TYPE OF URG IC IC I DELEAD DELEAD SURFACE HAZARD HAZI DATE METH DATE METH SURFACE HAZARD HAZ DATE METH DATE METH D UP Walls 0.1 AIM L N/A y Low Cab Fram ry' A/M L WA y Low Walls AIM L WA y A B Low Cab Door -V 3, AIM L WA y Baseboards , r AIM L N/A y C ow Cab Walls AIM L N/A y Chair Rail AIM L N/A y Low Cab Shivs v AIM L N/A y Radiator (' A/M L N/A Y 12 Supports AIM L NIA y Floor AIM L WA y 3 4 Drawers A/M L NIA y Ceiling (} ANL WA y A Window SM ,D ' M/l A/M L N/A y B Door a: AIM L N/A y B Win Apron AIM L NIA y C D Door Casing Q A/M L N/A y ©Win Casing AIM L NIA y 12 Doorjamb p ' A/M L N/A y D Header Stop `v M/I A/M L WA y 3 4 Threshold V AIM L N/A y Int Stops (/ M/1 AIM L WA y A Door AIM L WA y 1 Win int Sash 0.,0 MA A/M L N/A y C D Door Casing o AIM L N/A y 2 Exterior SM P1 l/ MA SF L N/A y 12 Doorjamb A/M L N/A y 3 Part Bead J MA L WA y 34 Threshold A/M L NIA y 4 Blind Stop M/1 SF L WA y A Closet Door ®.a A/M L N/A y 1WIn Ext Sash i! MA L N/A y (� Cl Casing AIM L N/A y A B Win Above 5' MA AIM L NA Y C Closet Jamb AIM L N/A y A B Ceiling Molding p/A/M.L NA Y D Closet Walls A/M L N/A y A Medicine Cab AIZ, M/I AAM L NA Y Cl Baseboard AIM L N/A y CIS Wall O/C MA A/M L NA Y 1 Closet Pole AIM L NIA y M/1 A/M L NA Y 2 Closet Shelf Q J AIM L N/A y MA A/M L NA Y 3 CI Supports . Q,( AIM L N/A y MA AAN L NA Y 4 Closet Floor .(,,r, AIM L N/A y M/1 AIM L NA Y Closet Ceiling A/M L WA y MA A/M L NA Y A B Up Cab Frame A/M L WA y M/I A/M L NA Y C D Up Cab Door AIM L N/A y IMA AIM L NA Y Up Cab Walls A/M L NIA y M/I AIM L NA Y 12 Up Cab Shlvs A/M L WA y M/1 A/M L NA Y 34 Supports A/M L NIA y MA A/M L NA Y MA AIM L JNA Y MII AIM L NA Y M/I A/M LY M/I AIM L NA Y M/1 AIM L Y MA A/M L NA I Y COMMENTS/STRUCTURAL DEFECTS: COMMENTS 1 STRUCTURAL DEFECTS: EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SQ.IN. DATE METHOD MORE THAN 288 SO.IN. DATE METHOD Page 10 of 17 Paula Prior I/R-3985 �� 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis HALLWAY: Interior # or Common Hallway: Front Rear Floor# SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZi DATE METH DATE METH SURFACE HAZARD HAZ1 DATE METH DATE METH Up Walls A/M L WA y q Closet Door A/M L NIA y Low Walls oh A/M L NIA y B Cl Casing A/M L N/A y p Baseboards -0 A/M L NIA y C Closet Jamb A/M L NIA y AD Chair Rail AIM L NIA y D Closet Walls A/M L NIA y A Radiator AIM L N/A y Cl Baseboard A/M L NIA y Floor AIM L N/A y t Closet Pole AIM L N/A y Ceiling A/M L N/A y 2 Closet Shelf AIM L WA y �B Door A/M L N/A y 3 Cl Supports A/M L N/A y C D Door Casing AIM L N/A y 4 Closet Floor AIM L NIA y I`-% Door Jamb 13.D AIM L NIA y Closet Ceiling A/M L N/A y 3 4 Threshold AIM L N/A y q Window$ill M/I AIM L NIA y Door A/M L NIA y B Win Apron AIM L N/A y C<D Door Casing A/M L NIA y C Win Casing AIM L N/A y Door Jamb 'AIM L N/A y D Header Stop Mli AIM L N/A y 3 4 Threshold AIM L N/A y Int Stops M/I AIM L N/A y Door AIM L N/A y 1 Win Int Sash M/I A/M L NIA y C D Door Casing A/M L N/A y 2 Exterior Sill M11 SF L N/A y 1.2 Door Jamb AIM L N/A y 3 Part Bead M/I L NIA y 3 4 Threshold /0' AIM L WA y 4 Blind Stop M/I SF L NIA y A B Door AIM L WA y Win Ext Sash M/I L N/A y D Door Casing L5 A/M L N/A y q Window Sill M11 A/M L N/A y Door Jamb AIM L N/A y B Win Apron AIM L NIA y 34 Threshold AIM L N/A y C Win Casing AIM L N/A y A B Door AIM L N/A y D Header Stop M/I AIM L N/A y (�D Door Casing A/M L N/A y Int Stops M/I AIM L N/A y Door Jamb 0.0 A/M L N/A y Win Int Sash M/I AIM L N/A y 3 4 Threshold AIM L N/A y 2 Exterior Sill Mn SF L N/A y q Closet Door AIM L N/A y 3 Part Bead MA L N/A y B Cl Casing U AIM L WA y 4 Blind Stop M/I SF L NIA y i(1 Closet Jamb Q, A/M L N/A y Win Ext Sash M/I L NIA y D Closet Walls Q A/M L N/A y D Win Above 6 AIM L N/A y Cl Baseboard AIM L N/A y Ceiling Molding AIM L N/A y 1 Closet Pole A/M L N/A y A/M L N/A y 2 Closet.Shelf AIM L N/A y COMMENTS/STRUCTURAL DEFECTS:. 3 CI Supports V A/M L N/A y 4 Closet Floor A/M L N/A y Closet Ceiling r AIM L NIA y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SID LOCATION MEASURE:LOOSE PAINT IC iC MORE THAN 288 S0.IN. DATE METHOD MORE THAN 288 SO..IN.) DATE METHOD r Page 11 of 17 Paula Prior I/R-3985 vn �i�/_ 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis KITCHEN SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ VLEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ. DATE METH DATE METH SURFACEHAZARD DATE METH DATE METH rQ Up Walls Q 3 AIM L WA Y A Window SillM/i A/M L WA Y Low Walls =��� A/M L N/A Y B Win Apron AIM L NIA Y Baseboards AIM L N/A Y Win Casing AIM L WA Y c Chair Rail A/M L WA Y D Header Stop M/I A/M L NIA Y o Radiator AIM L N/A Y Int Stops 00 M/i A/M L N/A Y Floor A/M L WA Y 1 Win Int Sash L M/l AIM L N/A Y Ceiling A/M L WA Y 2 Exterior Silt ' M/i SF L WA Y B Door AIM L N/A Y 3 Part Bead M/I L N/A Y C D Door Casing AIM L N/A Y 4 Blind Stop M/I SF L NIA Y 12 Door Jamb AIM L N/A Y Win Ext Sash M/I L N/A Y 3 4 iThreshofd AIM L N/A Y A Window Sill M/I A/M L N/A Y A B Door AIM L N/A Y B Win Apron A/M L WA Y D Door Casing —Q AIM L N/A Y C Win Casing A/M L N/A Y 12 Door Jamb AIM L WA Y D Header Stop A Mn AIM L N/A Y 3 4 Threshold .� A/M L WA Y Int Stops M/I AIM L WA Y A B Door AIM L WA Y 1 Win Int Sash M/I AIM L N/A Y C Door Casing AIM L N/A Y 2 Exterior Sill MA SF L N/A Y 1 2:Door Jamb A/M L N/A Y 3 Part Bead M/I L WA Y 3 4 Threshold (/ A/M L NIA Y 4 Blind Stop M/I SF L NIA Y AS Door AIM L N/A Y Win Fad Sash M/i L N/A Y C D Door Casing AIM L N/A Y Up Cab Frame_ A/M L N/A Y 12 Door Jamb A/M L N/A Y D Up Cab Door A 21 AIM L NIA Y 34 Threshold AIM L N/A Y Up Cab Wails A/M L N/A Y A Closet Door A/M L N/A Y 1 2 Up Cab Shlvs AIM L N/A Y B CI Casing AIM L N/A Y 3 4 Supports A/M L N/A Y C ClosetJamb AIM L N/A Y Low Cab Fram AIM L WA Y D Closet Wails AIM L N/A Y Low Cab Door -L} AIM L NIA Y Cl Baseboard AIM L N/A Y D Low Cab Walls A/M L N/A Y 1 Closet Pole AIM L N/A Y Low Cab Shlvs v AIM L N/A Y 2 Closet Shelf A/M L N/A Y 12 Supports AIM L N/A Y 3 Cl Supports A/M L WA Y 3 4 Drawers Gl3 A/M L N/A Y 4 laoset Floor AIM L N/A Y AB Win Above 5' A/M L WA Y Closet Ceiling A/M L N/A Y AIML N/A Y COMMENTS/STRUCTURAL DEFECTS: A/M L N/A Y AIM L N/A Y AIM L N/A Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader, SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SQ.IN. DATE METHOD MORE THAN 288 SO.IN. DATE METHOD I Page 12 of 17 Paula Prior I/R-3985 )ilL 11/18/14 Inspector(print) Llc# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: Hyannis BASEMENT/LAUNDRY AREA SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SIDELOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SURFACE HAZARD AZ DATE METH DATE METH SURFACE HAZARD DATE METH DATE METH Wad H AIM L WA Y AS Pipes AIM L NIA Y B Walls JA pjG AWN L N/A Y A Brn Sink AIM L NIA Y Wellsy L N/A Y A8 Drainpipe AN L NIA Y Walls AWN L N/A Y AS Seniteboard AIM L N/A Y All Baseboards AIM L N/A Y A B St1eNe6 AIM L N/A Y AB Chair Rail AIM L WA Y C D Supports AWN L NIA Y rn Floor AWN L N/A Y A B Shehres AIM L NIA Y r' Ceiling 1 G AIM C NIA Y (,D Supports AIM L WA Y Chimney L� AWN L WA Y A B Shelves AIM L N/A Y AS Support Colum AIM L NIA Y C D Supports AWN L NIA Y A B Door Q 3 A/M L N/A Y Window frame MW AIM L NIA Y 9DIDoor Casing 6 b AIM L N/A Y A B Window Sash MA AWN L NIA Y 1.2 Door Jamb o0 AIM L WA Y C D Exterior Sm Mn AIM L WA Y 34 Threshold AWN L N/A Y 12 Part Bead Mn AIM L N/A Y A Door AN L N/A Y 3 4 Win Ext Sash MW AIM L NIA Y C D Door Casing e E AIM L NIA Y WiMow tame MW AIM L NIA Y 12 Door Jamb ii A/M L N/A Y A B Window Sash M/I AIM L NIA Y 3 4 Threshold AIM L N/A Y C D Exterior Sal MW A/M L NIA Y A B Door ^ AWN L NIA Y 12 Part Bead MW AWN L NIA Y Cip Door Casing tj AWN L NIA Y 34 Win Ext Sash MW A/M L NIA Y 12 Door Jamb AIM L N/A Y Window frame MA AIM L N/A Y 3 4 Threshold AIM L NIA Y A B Window Sash 1. IM11 AIM L NIA Y B C Cabinets AIM L N/A Y C D Exterior Sill MW AIM L NIA Y A B Bendves AIM L N/A Y 12 Part Bead I MW AIM L N/A Y C D Supports A/M L N/A Y 3 4 Win Ext Sash M/I A/M L WA Y A Chet Door AIM L N/A Y Window frame M11 AIM L N/A Y B CI Casing AIM L NIA Y A B Window Sash MW A/M L WA Y C Closet Jamb AIM L WA Y C D Exterior SRI MW AIM L N/A Y D Closet Wads AWN L NIA Y 12 Part Bead MW AWN L N/A Y CI Baseboard AIM L N/A Y 3 4 Win Ext Sash MW AIM L WA Y 1 Closet Pole AWN L NIA Y Newel Posts 0 77 AIM L N/A Y 2 Closet Shelf AWN L N/A Y A B Handrail AIM L N/A Y 3 CI Supports AIM L N/A Y C D Balusters AIM L WA Y 4 Closet Floor AIM L N/A Y 12 Lower rail AIM L NIA Y Closet Ceding AIM L NIA Y 3 4 Treads _ „} A/M L WA Y Comments/Structural Qefects Risers A/M L WA Y Stringer A/M L WA Y AS Oil Tank L WA Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader. SIDE, LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC MORE THAN 288 SO.IN. DATE METHOD ORE THAN 288 SO.IN. DATE METHOD Page 13 of v Paula Prior IIR-3985 11/18/14 Inspector(print) L.ic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Pro 27 Hamden Cir Apt.# City: Hyannis CONTINUATION OF ROOM I&i^ SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD HAZI DATE METH DATE METH Window Sill M/I A/M L N/A Y A Window Sill t/ M/I AIM L N/A Y Win Apron A/M L WA. Y ,B Win Apron AIM L N/A Y C Win Casing —J. A/M L NIA Y Win Casing AIM L N/A Y D Header Stop ✓ M/I A/M L WA Y VVD Header Stop y, M/I AIM L NIA Y Int Stops /V(> MA A/M L N/A Y Int Stops V M/I AIM L N/A Y # I Win Int Sash MA AIM L N/A Y Win Int Sash M/I AIM L N/A Y Exterior Sill M/1 SF L WA Y Exterior Sill li M/I SF L N/A Y Part Bead fli(� MA L N/A Y Part Bead ' Mil L NIA Y Blind Stop M/I SF L WA Y Blind Stop M/I SF L NIA Y Win Ext Sash MA L N/A Y Win Ext Sash C. M/I L N/A Y A Window Sill f 0 M/I A/M L N/A Y A Window Sill M/I A/M L N/A Y Win Apron AIM L N/A Y B Win Apron AiM L N/A Y C Win Casing .J A/M L WA Y C Win Casing A/M'L N/A Y D Header Stop N.1 j Mli AIM L N/A Y D Header Stop M/1 A/M L N/A Y Int Stops N.v M/1 AIM L N/A Y Int Stops MA AIM L N/A Y # Win Int Sash .J MA AIM L N/A Y # Win Int Sash MA AIM L NIA Y v� Exterior$91Al.(, Mn SF L N/A Y Exterior Sill MA SF L NIA Y Part Bead M/1 L N/A Y Part Bead Mil L NIA Y Blind Stop M/I SF L N/A Y Blind Stop MA SF L N/A Y Win Ext Sash Nv M/I L N/A Y Win Ext Sash M/I L N/A Y A Window Sill %i MA AIM L WA Y A Window Sill M/1 AIM L N/A Y B Win Apron A/M L N/A Y B Win Apron AIM L N/A Y 0 Win Casing 00 AIM L N/A Y C Wfn Casing AIM L WA Y D Header Stop At, MA AIM L N/A Y D Header Stop MA AIM L N/A Y Int Stops (- M/I AIM L WA Y Int Stops M/I AIM L WA Y # Win Int Sash _ .i M/I A/M L N/A Y # Win Int Sash MA AIM L N/A Y Exterior Sill . L M/I SF L N/A Y Exterior Sill M/I SF L NIA Y Part Bead Nv MA L WA Y Part Bead MA L N/A Y Blind Stop M/I SF L NIA Y 611nd Stop MA SF L'WA Y Win Ext Sash .L/ M/I L WA Y Win Ext Sash MA L N/A Y t AIM L N/A Y A/M L N/A Y 0L d AIM L N/A Y n -0.t A/M L WA Y (n AIM L N/A Y G U .( I A/M L qN/AjY.0•D AIM L N/A Y rr A/M L YA/M L N/A Y AIM L Y COMMENTS/STRUCTURAL DEFECTS: COMMENTS/STRUCTURAL DEFECTS: 0 dJ f EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only b a licensed deleader. SIDE: LOCATION MEASURE:LOOSE PAINT IC IC SIDEJ LOCATION MEASURE:LOOSE PAINT IC. IC MORE THAN 288 SO.IN. DATE METHOD MORE THAN 288 SO.IN. DATE METHOD Page 14 of 17 Paula Prior I/R-3985 11/18/14 inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: ?7 Hamden Cir Apt.# city: HP-- EXTERIOR A Side SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD AZ DATE METH DATE METH Siding �. L WA Y Window Sill AIM L N/A Y Comer Boards a L WA Y A Win Casing AIM L WA Y A Lower Trim L WA Y # WlndowSash A/M:L WA. Y Upper Trim L WA Y Cellar Win Sin AIM L NIA Y Wm Above 5' L N/A Y A Cel Win Sash AIM L N/A Y Porch Above 5' L N/A Y # Cel Win Frame A/M L WA Y Storm Door AIM L N/A Y Screen Frame AIM L WA Y Dow A/M L N/A Y Cellar Win$19 AIM L NIA Y A Dow Casing (j. ' AIM L WA Y A Cal Win Sash j AIM L N/A Y 1 2 Door Jamb C. AIM L N/A Y # Cel Win Frame A/M L WA Y 3 4 Threshold N AIM L N/A Y Screen Frame A/M L NIA Y Kckplate -G. AIM L NIA Y Cellar Win Sill A/M L NIA Y Storrs Door A/M L NIA Y A Cel Win Sash AIM L N/A Y Dow A/M L NIA Y # Cel Win Frame A/M L WA Y A Door Casing AIM L N/A Y Screen Frame AIM L WA Y 1 2 Door Jamb _�.(� AIM L N/A Y Cellar Win Sill AIM L WA Y 3 4 Threshold AIM L N/A Y A Cel Win Sash AIM L WA Y K ckplate A/M L NIA Y # lCell Win Frame AIM L WA Y Door A/M L N/A Y Screen Frame AIM L WA Y A Dow Casing AIM L N/A Y Foundation r; L WA Y 1 2 Door Jamb AIM L NIA Y A Bulkhead A/M L NIA Y 3 4 Threshold AIM L N/A Y Fences A/M L NIA Y Window Sill ^ AIM L N/A Y Shutters A/M L WAI Y A Win Casing A/M L N/A Y Newel post A/M L WA Y #1 ]Window Sash. J AIM L N/A Y Railing Cap t" AIM L WA Y Window Sill AIM L N/A Y Handrail A/M L WA Y A Win Casing AN L NIA Y A Balusters ,,i AIM L WA Y #^ Window Sash ;J AIM L N/A Y Lower Rail J AIM L WA Y Window Sin AIM L N/A Y Treads W, AIM L N/A Y A Win Casing A/M L N/A Y Risers AM L WA Y # Window Sash AIM L N/A Y Stringer A/M L N/A Y A Lamp Post L N/A Y Lattice AIM L WA Y COMMENTS/STRUCTURAL DEFECTS: Drain Pipes L WA Y A Elec Conduit L WA Y Oil Fill Pipe L NIA1 Y Overhang Trim AIM L NIA I Y Excluded U aces:Surfaces listed in Ws box can W made Soil Test Results intact only by a licensed deleader Must be less than 400 ppm for play area 11200 pm for bare soil SIDE LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREMENT l2ESUL REMED REMED A MORE THAN 1440 SQ.IN. DATE I METH (Square Feet) (PPA DATE METH Play Area Bare soil A Comments: A f �, Page 15 of 17 Paula Prior I/R-3985 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt.# City: H�annic EXTERIOR B Side SIDE LOCATION/ LEAD TYPE OF URI IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SURFACE HAZARD HAZI DATE METH DATE METH SURFACE HAZARD HAZ DATE METH DATE METH Siding y L N/A Y Window Sig A/M L WA Y Comer Boards L N/A Y B Win Casing AIM L NIA Y B Lower Trim t NIA ` Y # Window Sash A/M L N/A Y Upper Trim L N/A Y Cel tar Win Sill A/M L NIA Y Win Above 5' .V L N/A Y B Cel Win Sash AIM L NIA Y Porch Above 5' L N/A Y # Cel Wn Frame AIM L N/A Y Stone Door A AIM L N/A Y Screen Frame A/M L N/A Y Door AIM L N/A Y Cellar Win SM AIM L NIA Y B Door Casing AIM L NIA Y B Cel Win Sash A/M L N/A Y 1 2 Door Jamb AIM L N/A Y # Cel Win Framel AIM L N/A Y 3 4 Threshold A/M L N/A Y Screen Frame A/M L NIA Y Kickplate A/M L WA Y Cellar Win Sill A/M L NIA Y Storm Door A/M L N/A Y B Cel Wm Sash A/M L N/A Y Door 1 A/M L NIA Y # Cell Win Frame AIM L N/A Y B Door Casing ° AIM L NIA Y Screen Frame AIM L NIA Y 1 2 Door Jamb AIM L N/A Y Cellar Win Sill A/M L WA Y 3 4 Threshold AIM L WA Y B Cal Win Sash AIM L N/A Y Mckplate A/M L WA Y # Cel Win Frame AIM L NIA Y Door ! A/M L N/A Y IScreen Frame A/M L N/A Y B Door Casing AIM L N/A Y Foundation L N/A Y 1 2 Door Jamb AIM L N/A Y B Bulkhead AIM L WA Y 3 4 Threshold AIM L N/A Y Fences AIM L N/A Y Window Sill A/M L NIA Y Shutters AIM L N/A Y B Win Casing AIM L NIA Y Newel post AIM L N/A Y # I Window Sash ,i j- A/M L N/A Y Railing Cap AIM L.N/A Y Window Silt AIM L N/A Y Handrail A/M L N/A Y B Win Casing AIM L NIA Y B Balusters AIM L NIA Y 1 # Window Sash Lf A/M L WA Y Lower Rail AIM L NIA Y Window Sill AIM L NIA Y Treads A/M L WA Y B Win Casing AIM L NIA Y Risers I A/M L NIA Y # Window Sash A/M L N/A Y Stringer AIM L N/A Y B 'Lamp Post L N/A I Y Lattice A/M L N/A Y COMMENTS/STRUCYJRAL DEFECTS: Drain Pipes L NIA Y B Elec Conduit L N/A Y Oil Fill Pipe L WA Y Overhang Trim AIM L N/A Y Excluded Surfaces:Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader Must be less than 400 ppm for play area/1200 DDm for bare soil rB LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREMENT UL REMED REMED MORE THAN 1440 SO.IN. DATE METH S uare Feet PP DATE METH PI Area Bare soil Comments: B Page 16 of 17 Paula Prior I/R-3985 11/18/14 Inspector(print) Uc# Signature Date Risk Assessor(print) Uc# Signature Date Address of Property: 27 Hamden Cir Apt.Al City: Nannis EXTERIOR C Side SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD DATE METH DATE METH Siding L N/A Y Window SID AIM L N/A Y Comer Boards L N/A Y C Win Casing AIM L N/A Y C Lower Trim �. . L N/A Y # Window Sash A/M L N/A Y Upper Trim -(j i L N/A Y Cellar Wm Sill AIM L NIA Y Win Above 5' L N/A Y C Cel Win Sash AIM L N/A Y Porch Above 5 L N/A Y # Cal Win Frame A/M L N/A Y Storm Door A/M L WA Y Saeen Frame AIM L WA Y Door A/M L NIA Y Cellar Wm Sill A/M L N/A Y C Door Casing AIM L NIA Y C Cell Win Sash A/M L N/A Y 1 2 Door Jamb (f AIM L N/A Y # CeI Win Frame AIM L N/A Y 3 4 Threshold ' AIM L N/A Y Screen Frame AIM L N/A Y K4plate AIM L N/A Y . Cellar Win Sill A/M L WA Y Storm Door AIM L WA Y C Cal Win Sash A/M L N/A Y Door A/M L WA Y # Ce[Win Frame A/M L WA Y C Door Casing AIM L WA Y Screen Frame AIM L N/A Y 1 2 Door Jamb AIM L N/A Y Cellar Win Sill AIM L WA Y 3 4 Threshold A/M L N/A Y C Cal Win Sash A/M L N/A Y Mckplate AIM L N/A Y # Cal Win Frame AIM L NIA Y Door AIM L N/A Y Screen Frame AIM L WA Y C Door Casing A/ML NIA Y Foundation L NIA Y 1 2 Door Jamb AIM L WA Y C Bulkhead -p AIM L N/A Y 3 4 Threshold A/M L NIA Y Fences AIM L N/A Y Wmdow.Sill A/M.L N/A Y Shutters AIM L WA Y C Wm Casing A/M L N/A Y Newel post �J{� A/M L N/A Y # Window Sash AIM L N/A Y Rai ing Cap AIM L N/A Y Window Sill A/M L WA Y Handrail �, AIM L NIA Y I'dC Win Casing A/M L WA Y C Balusters AIM L NIA Y # Window Sash N i,J AIM L N/A Y LoweEftl ' AIM L NIA Y Window Sill A/M L NIA Y Treadv AIM L WA Y C Win Casing AIM L N/A Y Risers vj J) AIM L NIA Y # Wndow Sash AM L NIA Y Stringer r A/M L N/A Y C N L NIA Y Lattice A/M L N/A Y COMMENTS!STRUCTURAL DEFECTS: Drain Pipes L WA Y C Elec Conduit L NIA Y Oil FIB Pipe L NIA Y Overhang Trim AIM L NIA Y Excluded Surfaces;Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader Must be less than 400 DDM for DIaV area 11200 DDm for bare soil SIDE LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREMENT RESULI REMED REMED C MORE THAN 1440 SO.IN. DATE METH Square Feet PPM DATE METH C Pla Area C Bare soil C Comments: C . Page 17 of 17 Paula Prior IIR-3985 11/18/14 Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property: 27 Hamden Cir Apt:# CRY: Hyannis EXTERIOR D Side. SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF UR IC IC DELEAD DELEAD SURFACE HAZARD DATE METH DATE METH SURFACE HAZARD HAZ DATE METH DATE METH Siding l L NIA Y Window Sill AIM L N/A Y Comer Boards L WA Y D Win Casing A/M L NIA Y D' Lower Trim L N/A Y # Window.Sash A/M L N/A' Y Upper Trim "� L WA Y Cellar Wm sill A/M L NIA Y Win Above 5' L NIA Y D Cel Win Sash AIM L N/A Y Porch Above 5' L WA Y # Cal Win Frame AIM L NIA Y Storm Door A/M L NIA Y Screen Frame AIM L N/A Y Door A/M L N/A Y Cellar Win Sill AIM L NIA Y D Door Casing A/M L NIA Y D Cel Win Sash AIM L NIA Y 1 2 Door Jamb A/M L WA Y # Cal Win Frame AIM L NIA Y 3 4 Threshold A/M L N/A Y Screen Frame AIM L WA Y Kickplate AIM L WA Y Cellar Wm Sill AIM L N/A Y Storm Door AIM L NIA Y D Cel Win Sash AIM L NIA Y Door A/M L WA Y # Cell Win Frame. AIM L NIA Y D Door Casing A/M L WA Y Screen Frame AIM L NIA Y 1 2 Door Jamb AIM L WA Y Cellar Wm Sill A/M L NIA Y 3 4 Threshold AIM L WA Y D Cel Win Sash AIM L N/A Y Kickplate A/M L WA Y # Cel Win Frame AIM L NIA Y Door A/M L WA Y Screen.Frame A/M L N/A Y D Door Casing j A/M L WA Y Foundation L NIA Y 1 2 Door Jamb AIM L N/A Y D Bulkhead AIM L N/A Y 3 4 Threshold AIM L NIA Y Fences AIM L NIA Y Window Sill (� AIM L N/A Y Shutters A/M L N/A Y D Win Casing A/M L WA Y Newel post AIM L N/A Y # Window sash A/M.L.N/A Y Railing Cap AIM L NIA Y Window Sig AIM L WA Y Handrail A/M L N/A Y D in Casing A/M L WA Y D Balusters AIM L NIA Y # Window Sash �, AIM L WA Y Lower Rail AIM L N/A Y Wardow Sill AIM L WA Y Treads A/M L N/A Y D jWn Casing A/M L WA Y Risers AIM L NIA Y # Window Sash AIM WPi Y Stringer AIM L NIA Y D I Lamp Post L NIA Y Lattice A/M L NIA Y COMMENTS/STRUCTURAL DEFECTS: Drain Pipes L N/A Y D Elec Conduit L NIA Y Oil Fill Pipe L N/A Y Overhang Trim AIM L N/A Y Excluded Surfaces:Surfaces listed in this box can be made Soil Test•ResuftS intact ordv by a licensed deleader Must be less than 400 DDm for Wav area/1200 m for bare soil SIDE LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREMENT RESUL REMED REMED D MORE THAN 1440 SO.IN. DATE METH (Square Feet PPM DATE METH D Play Area D Bare soli D Comments: D �., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is. required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town u State Zip Code Date of Inspection +. Inspection results must be submitted on this form. Inspection forms may not be altered in any µ way. Please see completeness checklist at the,end of the form. Important:When A. General Information ° .filling out forms ° on the computer, vl use only the tab key to move your 1. Inspector: cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason - ab Company Name - Y 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 . Telephone Number N License Number B. Certification CD I certijthat 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 pe&formed based on my training and experience in the proper function and maintenance of on site c, sewagl;disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of U— Title 5(310 CMR 15.000). The system: ® '�:asses ❑ Conditionally Passes' ❑ Fails Q as G1 ° ❑ Needs Further Evaluation by the Local,Approving Authority u Oct. 18,.2014 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"I0,000'gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer;if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 OfficilInspection Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form --,�/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a�;;J 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "`?�4 27 Hamden Circle t....r Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditional) Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94;/ 27 Hamden Circle L...r Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 1 _-- Title 5 Official Inspection Form R� — `i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \�9y 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every H annis MA 02601 Oct.18, 2014 y page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate L15,nsregional office of the Department. /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form F ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 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)] 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 I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -a4 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection D. System Information Description.- Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2013; 72,000 gallons and 2012; 39,000 gallons. Note; one meter for property Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No I Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form _...... _... Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts a} Title 5 Official Inspection Form '� Jr Subsurface Sewage Disposal System Form Not for Voluntary Assessments asi 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 _ page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 6/29/2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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: 1000 Gallon Typical Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts --: r Title 5 Official Inspection Form 9, ___ . -, - Sri Subsurface Sewage Disposal System Form - Not for Voluntary Assessments X 1r94 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 47" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle t...r Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover-. t Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Leaching field without inspection port. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Rf .1i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-32' long ❑ 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.): Soil probed and no indication. No surface ponding. No inspection port so unable to verify condition. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts _} # Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 9 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. CityFFown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form '= -- Subsurface Sewage Disposal System Form Not for Voluntary Assessments , c 27 Hamden Circle t...r Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18,.2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts } - r Title 5 Official Inspection Form 9 _ _- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Groundwater Contour Map Checked with I - ❑ t local excavators, installers (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater Contour Map I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Tf _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �4r' 27 Hamden Circle Property Address Brian Cory and Kristen Hansen Owner Owner's Name information is required for every Hyannis MA 02601 Oct.18, 2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION ;rc.L—_SEWAGE "40 I"-- VILLAGE_g*=Zj S ASSESSOR'S MAP&PARCEL 29/ 1� i - INSTALLER'S NAME&PHONE NO. j_4e A Ex= �n a;0^ y.7� SEPTIC TANK CAPACITY _j 000 cja J LEACHING FACILITY(t)pe) -k-cran h (size) C2 x NO.OF BEDROOMS OWNER__ orcc/ JslanSc/1_ PERMIT DATE:�! �j J A 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 Wedand and Leaching Facility(If any wetlands exist within _ 300 feet of leaching facility) Feet FURNISHED BY Al-Z All !33 i EI i No. '/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftphtatlon f or 13 osal 6pstem Construction i3Prmit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2.7 Hamei r n 6,-LL._ Owner's Name,Address,and Tel.No. t►�r s-F_n + 8�tnn Nansert Assessor's Map/Parcel a q I 'PgrLt- 11 9Z 2 n n is I ller's Name,Address,and Tel.No. 41l7-Dto5 D i3 ner's Name,Address,and Tel.N . o ber r t_-t t LPO V- B B ExCh�cATt ot� �f�l� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 7 Design Flow(min.required) 33 gpd Design flow provided gpd Plan Date !o Pt i to 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 Health. fil,& k (� Date Application Approved by 9' Date Application Disapproved Date for the following reasons oe Permit No. Date Issued ` �..gmtrys No. Feq 9 THE COMMONWEALTH OF MASSACHUSETTS Enterednitomputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitatiqu for M1sOisal16pstpm Construction Permit Application for a Permit to Construct( } Repair'(iUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 27 E'IAmc�e.(1 C►�L1�2..n 11r1 � 6i'1 n n Hn 1)s EtAssessor's Map/Parcel rte 19$ _ Installer's Name,Address,and Tel.No. 41 l-?•0(p 5 3 Designer's Name,Address,and Tel.NG. fit'Ober1- C-71Lrov- 131 i3 1x(AvAT16NI ( �i�L �iL1U14ejSUMfi�1;✓A(- DAuF .)iAs&q Ljr Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building -No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 U gpd Design flow provided gpd Plan Date 1/, 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 k Compliance has been issued by this Board of Health. Phav_�, Date 6 1 o Application Approved by Date r rApplication Disapproved 14 y d7 Date for the following reasons Permit No. Date Issued 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 has been constructed in)aaTce with the provisions of Title 5 and the for Disposal System Construction Permit No ed Installer ?/h6_?r_T 6 0_e 4 i Designer #bedrooms_� Approved den fl gpd The issuance of thi permi shall not be construed as a guarantee that the system will fu�c1ti n as de 'gned. C - Date � V Inspector �) i ------------------------------------------------------------------------------------ A-- --------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS ._._ Misposar �&pstem ConstrUttion 3wllPrintot Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at 277 W,cx r,p f-�,I .p ) ki x p r i—� i-1 i 4,--A✓6 A 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:Constructior must be ompleted within three years of the date of this permit. Date Approved by f Town of Barnstable Regulatory Services ;. Thomas F. Geiler,Director »' snR"rfs'�'itisLE, �.. Public Health Di�visi0n arFD ;�a Thomas McKean,Director 200 lain Street,Hyannis,MA 02601 Office:.508-862-4644- -Fax: 508-790-6304 Installer &Designer Certification Form Date: UI V4C Z"[ 1010 Designer: jVIJ7j: 0XX�� Installer: ��p Address: . `J�`�`L )lGH Address: lr.� t On was issued a permit to install a (date) (installer) ,� septic system at 14 ��•�•) 4Qf- - L-- based on a design drawn by (address) l� �• 'r� dated (designer) 1-certify that the septic system referenced above was installed substantially aacerdi' r e design, which may include mini- approved changes such as lateral relocandn of the iljstribution box and/or septic tank. I certify that the septic system:referenced above was msti&d tenth mafor_changes greater than�10' lateral relocataoi8 of the SAS or-any vertical reoca#iaa of arty componeuit of the.septi(._sy'stem)but in accordance with State&Local.Regi61ations. Plan revis ozk or certified as-bii t by desigraeDto follow. (Installers Si to e) sn l� SO4 vm FQf, TA.1. (I3 er s Signature) ( e gner''s Stamp Here) PLEASE RETURN TO BATS rAl >, +' PUBLIC HEALTH:DIVISION., C) RTDC TE OF C .'MZE = SSUED BOTR-`3'-S`iFORW BUILT gAAR2 ARE RECE E ?B'��THE:B. STA$LE ALTH DM SION THANK YGI7: Q:l-ealtlh/8eptic/Desib erCertifical7on Fora, , _ I Town of Barnstable P# 12177 Department of Regulatory Services .,►ar,eA" _ 'Public Health Division Date 200,Main Street,Hyannis MA 02601 4 Date Scheduled 2 a 3 Time�= Fee Pd. ,La i l Soil Suitability Assessment for Sewage° isposal Performed By: 11'D "� • ' �l Y Witnessed By: (A/. 1. LOCATION& GENERAL INFORMATION Location Address /,� ,°';��� Owner's Name Jai/( HYo �//j/j� Address Assessor's Map/Parcel: ( _ . /�/'I// Engineer's Name NEW CONSTRUCTION REPAIR -� Telephone# Land Use Slopes(9b) Suiface Stones - Distances from: Open Water Body_aft Possible Wet Area -ft Drinking Water Well _ ft Drainage Way ft Property Line /d ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of.test holes&perc tests,locate wetlands fn proximity to holes) w . . �T CO w� Parent material(geologic) / i Depth to Bedrock vv NO Depth to Groundwater. Standing Water in Hole: Weeping from Pit Race A: A Estimated Seasonal High Groundwater 0' DETERMINATIOWFOR SEASONAL HIGH WATER TABLE Method Used: sU Depth O s rved stan g in obs.hole: __ in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level; Adj.factor- Adj.Clroundwater Level, PERCOLATION TES`x Date�..�, Time. Observation Hole# ^� Time at 9" Depth of Perc CJ Z Time at 6" Start Pre-soak Time @ �'��" �' ; Time(9"-6") •� � At �"l End Pre-soak Rate MinJInch Site Suitability Assessment: site Passed Site Failed: Additional Testing Needed(Y/N) � t � Original: Public Health Division= �" 0 Observation Hold Data.To Be Completed on Back- ---------- ***If percolation test is to biconducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEfMC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistenc y, %GtaveD G G e-5 �7 " DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) .Mottling (Structure,Stones,Boulders. Consistency,% DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. tConsistency,%Gravel) u t i • i DEEPDBSERVATION HOLE LOG Hole# Depth from c Soil Horizon Soil Texture Soil Color ! Soil Other Surface(in.) j ! ( (USDA) (Munsell) ' ! Mottling (Structure,Stones',Boulders. Co nsistency. 4 f _ • C J Flood Insurance Rate Man: '.,?,, _ Above 500 year flood boundary No_ Yes t Within 500 year boundary No. Yes Within 100 year flood boundary No.✓/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi usgta 'al exist in all areiss•observed throughout the area proposed for the soil absorption system? ¢i If not,what is the depth of natural y occurring pe ious material?-Ajq' '`. " Certification ` ..N I certify that on '�� (date)I have passed the soil evaluatoi°examination approved by the Department of Envir mental Protection and that the above analysis was performed by me consistent with . the req ' ing,exper' perience described in 310 CMR•15.017. Date 6 Signatur 3 a/6 Q:\SBPTlMERCFORM.DOC f Town ®f BarnstableBnr'ast` ie , N � ie ulator Services Department 31KNSTA64E, . 6 : ,� Public Health Division � T f y. 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geder,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70083230000251782695 6/22/2010 Brian Hansen & Kristen Hansen QQ)T 27 Hamden Circle Hyannis MA 02601 . ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 27 Hamden Circle, Hyannis MA was last inspected on June 02, 2010, by Patrick T: Sullivan, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to 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 You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. a Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` °M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 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. Please see completeness checklist at the end of the form. Imp°rt 1lin A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-6055 S1 12843 Telephone Number License Number B. Certification 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 inspec�`ion 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: CD ❑ Passes ❑ Conditionally Passes ® Fails, ❑ Needs Further Evaluation by the Local Approving Authority JN : € sus M June 4, 2010 Inspector's Slgnat�ure— 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. i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for 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 indicat s that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 e 'st. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* r the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltr ion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repl ced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ N (Explain below): I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 Commonwealth of Massachusetts JAZv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high atic water level in the distribution box due to broken or obstructed pipe(s) or due to a brokenttled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ,/ ❑ Y ❑ N ❑ ND (Explain below): /j• ❑ obstruction is removed / ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or eplaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system requi ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Boar of Health: ❑ Conditions exist which require further evalua on 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 ealth determines in accordance with 310 CMR 15.303(1)(b)that the system is not f ctioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is withif 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil a sorption system (SAS) and the SAS is within 100 feet of a surface water supply or tr utary to a surface water supply. ❑ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SA and the SAS is less than 100 feet but 50 feet or more from a private water supply we *. Method used to determine distanc . **This system passes if the well ater analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and t presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" o "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 4 0 feet of a surface drinking water supply ❑ ❑ the system is withi 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ated in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) r a mapped Zone II of a public water supply well If you have answered "yes" to any uestion in Section E the system is considered a significant threat, or answered "yes" in Section D ove the large system has failed. The owner or operator of any large system considered a significa threat under Section E or failed under Section D shall upgrade the system in accordance with 3 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ent. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 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)] 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 GPD l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No 247 GPD = Water meter readings, if available (last 2 years usage (gpd)): 2002008 154 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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 Titl 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owners records: Pumped 1.5 years ago. 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 i ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 5/24/1978 As-built and Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): ABS35 Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8' X 4.5'X 4.5' 1000 gallons '5„ Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 I Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" 4" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet ABS tee and outlet concrete baffle in place. Liquid level at outlet invert at time of inspection. Staining over outlet invet present. -- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): i I Dimensions: Scum thickness Distance from top of scum t/of t tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and.Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y State Zip Code Date of Inspection every page. City/Town 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.): i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fj erglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 5" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid level over outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition/of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Type: ® leaching pits number: 1-6'X6'w/stone ❑ 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.): Liquid level in pit 8"over invert at time of inspection. High staining into riser. System is in failure. 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 l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y every.page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately f Q I t 3C ` � I I 01 l i f 'Y t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is Hyannis MA 02601 June 2, 2010 required for y every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >2feet 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: 1978 ' , 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water intrusion into basement. No ground water encountoured during system installation. Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 27 Hamden Circle Property Address Kristen and Brian Hansen Owner Owner's Name information is required for Hyannis MA 02601 June 2, 2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 72 � Fay...�s �. No..- FEE... ..., THE COMMONWEAtiTH OF MASSACHUSETTS BOARD OF HEALTH .- - - - Uli�....... ......... .. .OF...... �........-..-- ........----------------- A liratiuu -for Uispoiial Works Totwtrurtion Vrru - Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1At. L catio -Address Lot N . jj� ,� Owne dress Insta ler Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_--__-____� -----------------------------Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ---------------------------- No. of persons---------6--------------- Showers ( ) — Cafeteria ( ) Otherfixtures ...... ----------------------------------------------------------------------•-----------•---••-------•-•-•-••-------•--------•-------•--•---•------- WDesign Flow...............r.�0---------------------gallons per person per day. Total daily flow___________'�00....................gallons. Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter___._----_...__ Depth---------------- W Disposal Trench—No_____________________ Width--------------------- Tota di_______ .......... TQttal leaching area--------------------sq. ft. Seepage Pit No.___...k............ Diameter._,_( ____ Depth _.._ �,hfotal 1 aching area__________________sq. ft. z Other Distribution box ( ) Dosing tank ( ) G le J -7 7 aPercolation Test Results Performed by----------------_......................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit------------------_Depth to ground water-..____-___-- -_--_---- PLO Test Pit No. 2................minutes per inch Depth of Test _ Depth_Pit.................... p to gr ound water________________________ R+ -------- O --- --- -------�----- -- ------- .._. C.._.------------•----........................................................ Description of Soil------•------•----- --_ ------ -------------------•--------- ----------------------------------------------- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable._-_...________________________________________________________________________________________ r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of afth. Signed. ---- - .........; --- •- Date Application Approved BY .. ----------•---- �' 4/ -------- f . Date Application Disapproved for the following easo,s__________________________ --._.__._._.•--•--•---------•--------------•-._......_-•-----------------•--•----------------_...---._._.._..---•---•--•--•--------------------•------•-----------------=---------------....-------•----- Z _l �te PermitNo......................................................... Issued...... .............-................................. Date J No..........?.. ; Finc...eS.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .. . . ...... .OF...... :RIZQJ.$T Y+- -1 ........... ....... Aplifiration -for Ropaiitti Works Tonitrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at f ati Address srp+ -------- -------- - Lot o ft - - Ow- ow 12 Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-.-.---- .................................Expansion Attic (, ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.....--. ....... Showers ( ) — Cafeteria ( ) GI ,"' Other fixtures ----- -------------=-------------------------------- W Design Flow.............. _0..........._..--.__..gallons per person pet day. Total daily flow............1.400...................-gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width_... ......._.. Diameter---------..----- Depth--..----_-.--.-. x Disposal Trench No..................... Width.................... Tot n h ..... `��,t,al leaching area................_.-.sq. ft.. Seepage Pit No...... -------_---- Diameter.: . Depth '""�i�otal leaching area ------------sc ft. ���-- - P _... �.- M g< 1. Z Other Distribution box ( ) Dosing tank ( ) - Percolation Test Results Performed by-------------- --•-•-----------------------••------- --- Date.......................---------------- Test Pit No. L---------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---------.--.-..--.-- f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--------------------------- W /-----------------•---......-----------••---•-------------•------------- .- O Description of Soil................... ..-- O x a t � W - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................----------------------------------------- -------------------------------------. •--•-•--•-•---------------------------••-----.-...--------------------------------------------•--•----------••---------•-------...----•-------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beensissued by the board of health. —)Sign d '�� ���?�. •--- -------•----Date-•--•--------- f%"/ ��j Application Approved By----- --•.... _ ` -='�--------------�.....� `� %'.:.- — 7 V Date Application Disapproved for the following-reasons:--••----••-•-------------------•-------•-------•-------••-----........-..-•-----•-----•-----------------•------- •••••-....--•----•--••--•--•-•-•-•-••-....---•---------------•--•--------••--•--•-•---•...--•--•-•-------------••---------••----•-•--------•------------...•---------------------•-•--.....---------•-•. Date PermitNo......................................................... Issued-----------------------•--------------------•-.......-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL T -�....0 .+.............OF.-...... ..... �rrtif irate of fI'limVIianrr / THIS S ;CE IFY, Th the Itqdividual Sewage Disposal System constructed (�) or Repaired ( ) by.......- J \ [� Int 11 at _S._-..----- �. ..-•-------:-----f/ ��'i -- - - --•-----•-------•----- has been installed in accordance with the provisions of t tic ••XI f The State Sanitary Code as described in the application for Disposal Works Construction Permit No. 77.... `1_ ______________ dated- -./... - 77: .••... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM 1NILL,Y,—U<�TION SA�SF�CTORY. ��,,99�� DATE. ------•-•-- .....--•-•--. Inspector-------------------------------.... -------------------------------•--------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH / 07!'-; .-... ...OF.....-.... '� . ..... ............................L �No. --���-- FEE16. r � n5trn�ttt�It �rrnttt Permission is hereby granted - ------ ............................................................. to Construct ( ) o . Repair,( ) Indivi �ualBe Disp sal S stem at No..� �r--------��-------�lJX1 ` d <G` ---- Street as shown on the application for Disposal Works Construction Pe 't No.-.--.. 00;i1qd-..7.:7/,.-2Z-__......... ------------------ { Board of Health DATE^ -- ' - ---- ------------------------- ----•------------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No........................... Fim........ THE COMMONWEALTH OF MASSACHUSETTS J BOARD 0 HEALTH ---------------OF.........-.. . ...... ........................................ Appliration -for Riipoiial lVarka Tomitrurtion Vautit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst at 55— ----T- X41�&4 .7 /---------.---.-.-.-.-.-.-.-.-.I.... ...... ...Location, ress Y.a.....,... or t Z..N 4Qner ' Addres.s........ ..................... e . ................................................................ Installer Address -tll Type of Building, Size Lot--. ------Sq. feet Dwelling Z No. of Bedrooms---------- E--------------------------------- xpansionAttic Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons.-------jV--------------- Showers Cafeteria ( ) P-4 Otherfiat es ----------------------------------------------------------------------------------------------------•------------------------------------------------ Design Flow_____________-------0.................gallons per person per day. Total daily flow............3—-------------------gallons. x Septic Tank—Liquid capacity-NA-01 gallons Length---------------- Width__........-.._.. Diameter--------- ...... Depth.--_._._..._--. Disposal Trench No..................... Width...._......._....... Total Length._....._...._._.... Total leaplj' sq. f t. pg area.............. Seepage Pit No. Diameter__ ___ DePA' et F1,ti --------------- bpta�l Z Other Distribution box Dosing tank 7 - -------------sq. f t. Percolation Test Results Performed by------------- -------------- Date---------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..-._----_-.-.---------- - (� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water................___..... -------------- .... . ............................................ 0 Description of Soil------------------------------ ------------------------------------------------------------------------- �4 -�-----;;----- ------------------------------ U ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- ............................... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health n -------------------------------- Date Application Approved By-------------- -------------------- ...... ............................ 7r, ----- ------------- Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ......................................................................................................................................................................................................... Date PermitNo........................................................ Issued...................... ------.......................... Date No......................... FlC$............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applirtt#ion -fur Mipniat Workii Towi#rnr#iLin Prxnti# Application is hereby made for a Permit to Construct 6—)—or Repair ( ) 'an Individual Sewage Disposal System )) / Locatiioon� or Lot No. .... .__ - •t��F. ...................hh-._.-�................ ................................................................................................. Address �..-=•--• -••j'---•-•"ram"•-~-".."-•••-• ....................... ..................................•-•--- Installer Address Q Type of Building -� Size Lot----------------------------Sq. feet U Dwelling No. of Bedroom - -�............. . .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures Y d _ ----------- -------------------------------------------- W Desi n Flow. P P P y y --T ---------------------gallons. g . . .. (�...y�___________________ 111ons per person per day. Total Bail flow___.__._. ... W Septic Tcutk Liquid capacity_�� -- allons Length-------------r. Vidfl. _._....._.._.. Diameter__-_-- Depth................ a ---------- x Disposal Trench—No. ................... Width._.::__S,�_- f otal Length-------------------- Total leaching area--------------------sq. ft. ............. Diameter/_-- -------- L epth below inlet__-____________-_-_- Total leaching area------- {t. Seepage Pit No...... z Other Distribution box. ( ) Dosing tank aPercolation Test Results Performed by............... ...... ................ Date-___-_--___---_-__-__.-_-.._--_---.-._.. Test Pit No. I...._-----------minutes per inch Depth of Test Pit.................... Depth to ground water......._.___-.-_.-.__.. G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__._.....__-...____-___. O Description of Soil............................................................ x V ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------------------_ ----••-----------------•---•------------------------------------------------------------•---------------------------•-------•------------------------------------------•---......_..--- ------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. , ;/ l Date_ Application Approved By.__...----- ,�__ �� �h/4- &;'`� .7.. �..:.. 4lf '. J 7 Date Application Disapproved for the following reasons:----••---------•----------------•----------•-----•-----••-----..............................••-•-•._.........--- ...........................•••--•-•---------•----------------••-•-•-••--...--•-------•-•--••••••••••••••-'-----.......---•- ........................................... ................................. Date PermitNo.....................................- .................. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH:;,_ ,;, ..OF........... ... 1 ................................................. (UPrr#ifira#r Lif f�nnt�rti�tnrr THI IS C�;-TIFY, Th the►Invidual Sewage Disposal System constrizcfed (�r Repaired ( ) by- -•-- ••• ------- - ------- ta, ..---- --------------------------------------------------------------------•------------- Installer _ at . 7_... ---------- --------- ---------------------------------------------------------------•---------•-•------------------- has been installed in accordance with the provisions of : is XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. �71__ _ ______________ dated..._ _�_ .... 7_............_.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE SYSTEM 1NIL4 UPICTIOPI SATISFACTORY. DATE--------•••• `-............-_� ............................ Inspector---- `.----( THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 77 �� .......... 1_... ..of.......... .............---...------------------..................... No......................... FEE........................ Bi-spvafittl Vili (nn #rnr#inn rruti# Permission is hereby granted___"- :. •. ---_ to Constru or Re air an Indiv dual S e t osal System at No. 4 St r t as shown on the application for Disposal Works Construction P No.. .... .......,_. Dated -----7 �__........ •. ( � « Board of Health DATE ---.....-- ( ... .............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ASSESSORS MAP : `z9/_ TEST HOLE LOGS NOTES: PARCEL-: �/�3� FLOOD ZONE : 501 L EVALUATOR : U(D WITNESS : '�V I C� �'r 1,.1 1) The installation shall comply with Title V and Town of��(N5iWBoard of c REFERENCE : OF �,L c, ! F - '� ! DATE: U ' U Health Regulations. i(/p,r�'m r9 tom' ✓�(j��rNJ ,lZ �5 ,l PERCOLATION RATE : L y I 2) The installer shall verify the location of utilities, sewer inverts and septic components prior to installation and setting base elevations. i 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot_The first TH- I TH-2 two feet out of the d-box to the leaching shall be level. O � lA►� LD)`( J� 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation: LV 5) All septic components must meet Title V specifications. ` Lo'� 6) Parking shall not be constructed over H10 septic components. LOCATION MAPS 7 The property is bounded b propertycomers and roe lines. �� � 8) The ppy owner shall reviewi p P property gn considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed �--- approval of the design flow by the owner_ 9 The existing leaching or cesspools } g g pools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed>aiong with contaminated soil and replaced with clean sand per 2 Title V specs. Zg 9 � b. 10)System components to be 10 feet from water line. Sewer lines crossing the ' '11L ._Ijt 7 water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service 3b line. The line is to be sleeved as aforementioned and maintained in place. / ZZ __T 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. r ; r f i 12)The installer is to take caution in excavation around the gas line if such 2 I 'A -r' ( , , � J BEDROOMS AT BCD G L/DAY/BEDROOM - 2 GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling rior to the installation.P ^ K _, +`AL/DAY x 2 DAYS - L6D GAL � a r� #� � USE �� GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM I �, �`� - 2 �►Z C G. -c`� Z 1-��l u� l�J� gyp,0¢ Z1 Z SIDE AREA: Z 7\ Z- X vz�-� X Z �( t ? - �b , acfN , ,, , x BOTTOM AREA: 2 lo o ±F-�? .. +'"��ot,.jiR;A r tom' f ir , {' -- 14Tt4L _ .L,-fit ! ' -- SEPTIC SYSTEM SECTION CT21-tl1.71A1 ��=>V `f,{7� Z7,CJ 725 �. �� GAL ZS �1Z �6-� - 2�;f fi �.3�9 i�i I ouo tom ✓ �e,1 SEPTIC TANK 4, -7 I i I 5 1 ois - - - ~' �. SITE AND SEWAGE PLAN --- < LOCATION : 2_7 H �A"DFvl l)?GUF_ 4 PREPARED FOR : x&�q° SCALE : I DAV I D B . MASON17,_'5 DATE : G /O DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2 1 77 Z - yx.K 4`s� 1, ar 71 L) rT US k' t• t ��? rc 6• d k 1 Ew P L J��A 51 j • j TYPtGAi.. 'S�T"tC TI►�4G. TYPi G� C�tS T"2.t Dv� ( �?N �3caX.. MOT TO ZCA.6.E ►J Or_ -rb 5 _.A,L.E. • Frwlf u� G�R.i►Ps ■ Y.� F`,N�s�l rwLsoE �{NtSM 4Y.�� •. . at alL - Ov[rR. Trw�� _��.': > Uvr[� �i • wF ( f !Ssa. 0 tl ws Q X* - � •I OO© i"1'+r�. p1'gT �Q17(, � � � o 0 0 0 � 'r+�'��? .�7f9 nt%* .� ' ' ;� �i�yMb�csp C�w.G I ; � • � • o • IMI+ 1•t.> s (, 5� �y�� ,/ ` O r 1 � TQ►�j R AN wear ro 94A"X J r \` b k fJ) i I U = 00 16 .4 NV SC-onc rvtiK 14 SCALE OATS: owTAwH BY t++Ko BY aPvU ar rs.wti NO � , 1 1 `. 11 'sF S�D 49 L fLIQU�D LEVEL. _l } A.ru t � IFS -- � � - - - - - - - - - TYptGAL Sce'ric TAJ`1{L TyPI CAL_ CAST-Q-(DvT- 1 0" BC)X- ►dOT To ncA L.E N OT- TO 5c. L.E IF • �iCno� - F�+��S.r 6�rs nE F i►.��S H 6 sso iE T � d o -- - a is C - C IC F 1 c•.sr F .•�:.. C _ �.: \� �/ Ir,. � ,(-� 4d ►..7n4 V V } � LC�Gr+ e�'_ T�YT • . )000 rZs� _ _8 :, QE�►•�RacGiO ca.c D15T gOX V 1 • • �� �+ ` r cutu:.�+G� 3'�dni� Tb gE. LEVEL i 1 4W per& S x S KLOT To xALiL L 'V PRoF ,CI)WZ44.1 14C, 6ofW A?- N WX 0 k' Q I 4b t� • 3 ,� s i��,tc ,•� rEsr ,yam r ^ Vl �lN �i } 9 4 L o pexse � ��.�.e.t�.l ST',��i L.-•.��„l-••��/�''1�1►-1►S r�. � �j`j , � �` �, SCALE OAT(. M 9T r� DRAWN 6Y (-HKD Ov APPO Br PI-AM Poo r �