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0005 HOUGHTON ROAD - Health
5 Hough"ton Road Hyannis A =.306 238 ` f � i t TOWN OF BARNSTABLE ' LOCATION S �Ov-her\ ��A SEWAGE# nc>P VILLAGE ASSESSOR'S MAP&PARCEL. IN h�'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1!�UL �-Q LEACHING FACILITY:(type) (size) .,NO.OF BEDROOMS L'I OWNER i r 1 © PERMIT DATE: G9M#1-4A=E DATE:—rr, P 10 1o;Pl ob Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY Y Y 'v 'v Y f'v v. '•. Y v '• Y •+r� k'Y . f f { f J f f J :' f'~i ? :' i+'J`i i i of f � ! •• . Y krY Y 4 Y Y Y Y Y '•. 'ti Y '. Y 'v '•. .�YfY Y v Y JY iY Y f�. yfYf YiY y�A{dr 41� .+t Y+Yf Yf Y' t fM1 - Y 15 28 �r 15 38 - Water Service 3 Houghton Road s h. Town of Barnstable Barnstable Regulatory Services Department ';m"aC j RARNSMULY- _ "�: ,�� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1647 January 13, 2014 i Vladimir Formanek & Jamlia Talhi 57 Hickok Road %MJB LLC New Canaan, CT 06480 IMPORTANT NOTIC Map & Parcel 306-238 The Department of Public Works informed us that public sewer lines are now available in • your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 5 Houghton Road, Hyannis, MA, to public sewer on or before 3/01/2016. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection,please see enclosure. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health • Enc. Q:\SEWER connect\Sample order letters for sewer connection\5 Houghton Rd Hy Jan 2014.doc I No.6LO C Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ Yess PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpphLation for Misposal 6pstrm ConstCUttion Permit Application for a Permit to Construc ) Repair( Upgrade(') Abandon M/0 Complete System ElIndividual Components Location Address or Lot No. : gq� e\ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i� 3 t�b �' W K�r\ k St Installer's Name,Address,and Tel.No.5rOi5-- 3 6 O—7630 Designer's Name,Address,and Tel.No. Type o uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature �of�Repairs or Alterations(Answer when applicable) ��1 [r• 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 thisABofAHe th X Signe Date it a— Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued r No. �O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION,--TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal *pstrm Construction 3permit Application for a Permit to Construc �Re it Upgrade(gAbandon Complete System Individual Components PP ) P ( �) ❑ P Y ❑ P Location Address or Lot No. ; �W, p^ A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ' " 3 C? )- Kc r\("\ ,q S're\, Installer's Name,Address,and Tel.No.5oL� 3 6 p Designer's Name,Address,and Tel.No. Type of Building: Dwelling, 'No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) r Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow(min.required) ri gpd Design flow provided" ' E, gpd Plan Date r Number of sheets 3 x Revision Date i• Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)r "v 0n �-aru. - Date last inspected: Agreement: The �' a Y g P undersigned agrees to ensure the construction and maintenance of the afore described on-site sews disposal system in g 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 f He X Signed ° _ Date i ____�� Application Approved by `�L ry%.. ��' •/ �S - _ Date Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS,, Certificate of Compliance T�FIIS�I TO`CERTIFY;that the O in-s tONSewage DisposaI system Constructed( ) -,Repaired( ) Upgraded( ) Abandoned b J �Lt l !�C f-.k �l r1 CR i� ( Y at yrO .n Lq"e, h 'Iarnn•s has been constructed i acco ce with the provisions itle 5 and the for Disposal System Construction Permit No. / '� daVd Installer _ Designer d #bedrooms Approved design,flow /y gpd/1 A r The issuance of this permit sh ll not b can ed " a guarantee that the system wihfl/functionn as design ed(�`v�, /��/ Date / ( Inspector //C ((i ! (/ "L� Yi U I d� l/L� --------- --------------------------------------- ------------------------------------------------------------------------------------- No. c?, o Jn Fee t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstemkonstrUction errnit 4 4 , �, Permission is hereby granted to Construct( ) Repair(/ /) Up ade( ) Abandon System-located at and as described in the above Application for Dispo al System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or-special conditions. Provided:qCrjctio,n must be completed within three years of the date of this permit. L Date Approved by y%y !� l ►" r AsBuilt Page 1 of 1 TOWN OF ^BARN/STABLE LOCATION S J9�GtL�,h9�in C o SEWAGE iv VILLAGE ASSESSOR'S MAP & LOT 306-Oar INSTALLER'S NAME & PHONE NO.-R�X4dO& n,), : 9-f- a SEPTIC TANK CAPACITY /-Svc, g`'� LEACHING FACILITY type) (size) 7 / NO.OF BEDROOMS_ PRIVATE WELL _UBL IC WATER BUILDER OR W E DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes I No 35 y/r w/.1 rT 5*me- r� un�l.^ http://issgl2/intranet/propdata/prebuilt.aspx?mappar=306238&seq=1 9/3/2014 No... )-o I Lf3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Mt!9posal �&pgtem Con.5tructfon Permit Application for a Permit to Construct( ) Repair(0 Upgrade( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. 57 qw-Im.% ee IRD. Owner's Name,Address,and Tel.No. f{-4fNv\v\14 VvNft. 02(ae!j \1 LAr-in kN F--r-muntK A,v4 -TR—loci TA1-14 Assessor'sMap/parcel VkAp 3C(r, (�Lcc-. V: S 4'6t tejEiLcg'r 6TIRi -r wei,TwaOt�, tr'vi6. L-1LD10 Installer's Name,Address,and Tel.No. 50 8-4T7-S 8-7 7 Designer's Name,Address and Tel.No. Cr�ae usiD E ��vTt""�vi s•c S�t_lc �S3 Cor»rnear�rc� � /L[rh3itPeE` 6Y�IQ- �L��� `v/� Type of Building: Dwelling No.of Bedrooms > Lot Size ;�00 3 sq. ft. Garbage Grinder ( ) Other Type of Building ►Z 141c�y„r 1- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan ,Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) & L A-CC-r— ID -Rg% Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date C oZ a 13 Application Approved by oot LS Date —5 Application Disapproved by: Date for the following reasons Permit No. Date Issued No. �G L[/ � Fee �V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for �Dizpogal *p5tem Cou5truction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑ Complete System Individual Components . Location Address or Lot No. $ VA v v taH%oN IUD. Owner's Name,Address,and Tel.No. w4AY\VNI5 mfv. oLtaol V t-Ar:Aim%m 1*ormawNeK A N b jnroiI•lyTAL41' Assessor'sMap/parcel ►MAP 3o(o f3kr (S/- 23`e3 430 1_vt(LeTf STQEX_I' Wes'cwoob-, ►AA. 07-D t0 Installer's Name,Address,and Tel.No. , 50 8-477-S S 7 7 Designer's Name,Address and Tel.No. CA%-�,EwtoE C,vTt_-V-Pn9<s ,Lu• . ^^ , (vA_,jme cc.c+i- ST- I>4MHPee, 044- .OLtm` 1 t4 � 1A Type of Building: Dwelling No.of Bedrooms �T Lot Size 3 7 sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min:required) N gpd Design flow provided A.1gpd Plan .Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of"Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: .Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ,- Signed Date 0 1 Application Approved by � f' — }, Date Application Disapproved by: Date for the following reasons Permit No. G� Date Issued _�3 }' THE COMMONWEALTH OF MASSACHUSETTS � 1 BARNSTABLE,MASSACHUSETTS L Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( A) Upgraded ( ) Abandoned( )by CAV z,ji6E LCG at S 1 u(oNDiu P-b . lj`ll4'y\n%S M A, a Z(v a 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. olG/3-t 3 _ dated LI-151 3 . Installer L-.J2NlZrrn u s Lte Designer N L #bedrooms Approved des A/ gpd The issuance of this perm't slia no�be c nstrued as a guarantee that the system wiC-Igniflio1w €u�nct n desg ed �� Date J s Inspector � y -------------------- No. U(� J I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migont *p!gtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) System located at E-W o UCH ?Dail X D K YA Al and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this perm Date Approved by 1 f _... Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner owner's Name Information is required for every Hyannis MA 0260;1 11-6-13 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. Important:when filling out forms A. General Information „tunirr►1„ �,A q on the computer, 0Fl,yQSvii,,G use only the tab 1. inspector: ;���s� � ' •s9C'y key to move your =O:• • G cursor-do not JAMES .lames D.Sears V _ � use the return key. Name of Inspector :v� CapewideEnterprises,LLC {s,�� ,s�„�- _��- �; Company Name �i,�l�c •• G ��� 153 Commercial Street 'O�� SriiN 5P�``�p�` Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 Telsphone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 16.340 of Title 5(310 CMR 16.000).The system: Passes ❑ Conditionally Passes : ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority u...a rn A'� k cr,, ,, 11-7-13 r�r spector's signature Date =� Ttte,.system inspector,shall submit a copy of this inspection report to the Approving Authority(Board c of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or design flow of 10,000 gpd or greater, the inspector and the system owner shall.submit the re°port to the appropriate regional office of the DEP. The original should be sent to the system owner F. C:1_1 43Apicopies 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. t5 ins•3113 Title 5 offid ion Form:Subwdsw Se rage Disposal System•Page 1 of 17 ivov Ua io UD.ocp p.Z Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi owner Owner's Name information is required for every Hyannis MA 02601 11-6-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to.be, replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes',"no'or"not determined"(Y, N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank wi(1 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): t9ns•3113 Title 5 Offi®i lnspecOw Ftxm:SLbawfaoe Sempe Disposal SYMM•Pape 2 or 17 IVOV.uts.a 3 uo:0 i p p.0 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information is Hyannis MA 02601 11-6-13 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms not operational.System will'pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes(cunt): ❑ 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 Boar 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•3113 Title 5 Ofri W Mpection Form:Subsaface Sewage Disposal System•Page 3 of 1T f IVUV VO IJ Vz):Z)I p,y Commonwealth of Massachusetts Umono Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information Is required for every .Hyannis MA 02601 11-6-13 page. citylrow n 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 boxabove outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in sesspee is less than 6" below invert or available volume is less than Y2 day flow.L l`,,4c111tiG l5Yis-3113 TWO 5 MOW MSP8 Son FOM Subswfaoe Sawape Dlaposal Syslem•Papa 4 of 17 rvuv vo to Vo;o I P.o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Narne information is Hyannis MA 02601 11-6-13 required for every page, Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Cl ® 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 20009pd- 10,000gpd. ❑ Eg The system fail$.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 Il.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 16.304,The system owner should contact the appropriate regional office of the Department. t&ns•343 Tile 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 or 17 INOV UO I J UO:0Gp N.o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd Property Address Jamilia Talhi Owner Owner's Name information is Hyannis MA 02601 11-6-13 required for every page. Citylrown 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 NIA) ❑ 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. El ® Determined in the field (if any of the failure criteria related to Part C is at'issue approximation of distance is unacceptabie) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 440 Ming 3f73 Tft 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Ivov uu l3 u5:5[p P.f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information is required for every Hyannis MA 02601 11-6-13 - page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank D Box and six infiltrators. 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 Z No s 6,000GaI Water meter readings, if available(last 2 years usage(gpd)): 2011-2012-1 ,000Gas Detail: Sump pump? ❑ Yes ® No �Last date of occupancy: NA CommerciaUlndusttrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Gins•3l13 rift 5 Ofridal Inspedion Form:SubmMaw SewaW Disposal System Pape 7 of 17 IVUV UO I o UO.Z)/-p IJ.O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd Property Address Jamilia Talhi Owner Owner's Name information Is Hyannis MA 02601 11-6-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): !Sins-3M3 Title s onkw hspedion form:subsLdsm Swmpe DisposM Symem'Page 8 d 17 •ivov uu '16 uo:WID p.a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information it required for every Hyannis MA 02601 11-6-13 page. cityrrown state Zip Code Date of Inspedion D. System Information (cost.) Approximate age of all components, date installed (if known)and source of information: 1994 Permit # 94 -739 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site.plan): Depth below grade: 40"feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH-40 Septic Tank(locate on site plan): Depth below grade: 29"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: 1500 Sludge depth: 0p, Mns•W 13 rift 5 OW31 kopect m Form Subsurface Sawsp System Pape 9 of 17 Ivov uu IJ UD:Dop P.I V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd Property Address Jamilia Talhi Owner Owner's Name information is H annis MA 02601 11-6-13 required.for every Y page. C4 rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness NA Distance.from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Asbuilt and Tape How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank level low. No solids or scum.Tank and.outlet cover at 29"below grade w/inlet cover at 4". in and out let tee's No sign of leakage or over loading 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 Gins 3113 Title 5 OifloiW Inspection Form:SuDsvfaw Seiage Disposal System•Pape 10 of 17 f IVOV UO 'I.9 110:aJp P. I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information is required for every Hyannis MA 02601 11-6-13 page, Cityrrown state Zlp Code Date of Inspection D. System Information (corn.) 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 t5ns•3113 Tft 5 Official Inspection Fomr SLbsurfaos Sewage Disposal System•Page 11 of 17 IVVV VO IJVJ.UL+p P. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name require for is Hyannis MA 02601 11-6-13 required for every page_ Cityrrown State Zip Code Oabeof Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D Box is 16"x2V-3' below grade w/cover at W'. Box is new 11-2013 w/three line's out 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: tSrra-3M3 7ele s offiew hlepeetion Form:sumLeaoe Sewage DivooW System•Pape 12 0117 Nov UO IJ V0:Z)4p P. 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address - Jamilia Talhi Owner ere Name information is required for every �R�m MA 02601 11-6-13 e t State Zip Code Date of Inspection D. System Information(cost.) Type: ❑ leaching pits number leaching chambers number. 6 Cl leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs.of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is six infiltrators w/2' stone. Ck D Box and camera out to chambers. Chamber's are clean and dry. No sign of overloading.or solid cagy over. No sign of holding water. 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 t5ns•3113 Title 5 Olridal Inspection Forrte Subsurface Ssw"e OispoBel Syslem•Pepe 13 or 17 ivov Uo f 3 L)o:o4p P.14 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information Is Hyannis required for every MA D2601 11-6-13 page. City/Town State Zip Code Date of-Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): I 15ins 3113 Title 5 official tnspedlon Form:Subswfece Sewage DuVwal System-Page 14 of 17 ivov Ud -i s Uo:oop P.-I o Commonwealth of Massachusetts NumTitle 5 Oi#i vial Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owner's Name information is required for every Hyannis MA .02601 11-6-13 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 14 3 154—-31t 3 TWO 5 OMCW 1 nspeebon Form SuCs+rreoa Sewage Disposal SyL1em-Pays 15 of 17 Nov Ud 1:3 Ub:bbp p.1 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner. Owner's Name information is Hyannis MA 02601 11-6-13 required for every Page. cityRown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells a N Estimated depth toFigh ground water: 1 o,+1 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: 12-20-94 Date [] Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.1994 10'no G.W.. Bottom of chambers at 4'. Bottom of chambers at 6'above T.H. Depth. . Before filing this Inspection Report,please see Report Completeness Checklist an next page. L5ins-3113 Title 5 Official Inspection Forth:Subsurface Sw4mge Disposal System•Pegs 16 of 17 IVUV UO IJ UU.UUP P, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Houghton Rd. Property Address Jamilia Talhi Owner Owners Name information is required for every Hyannis mA 02601 11-6-13 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•3113 Title 5 Oftal hWedon Fomr Subsulfew Sewape Dispose!System•Pape 17 of 17 r •f' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal_System Form - Not for,Voluntary Assessments w„ 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information 4 forms on the computer,use 1. Inspector: u� only the tab key _to move your Patrick M. O'Connell cursor-do not Name of.lnspector use the return key. . Septic Inspection Services Co.. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fail's ❑ Needs Further Evaluation by the Local Approving Authority �r^1 'v\ December 29, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. L 11oq 08-311 Caggiano.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Dislus-1 System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system had no standing water or evidence of surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection it it is"structurally sound, not leaking.-and.if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution.box. System will pass inspection if(with approval of Board of Health). ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-311 Caggiano.doc•08/D6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, . safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health; safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone.1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-311 Caggiano.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. CitylT'own State Zip Code Date of Inspection B. Certification (Cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No El ® 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 El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- El ® 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. 08-311 Caggiano.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat,. or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08.311 Caggiano.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is Hyannis MA 02601 December 29, 2008 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? 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)) 08-311 Caggiano.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is H required for Y annis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-311 Caggiano.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 5/10/02 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑. Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Permit date: 12/21/94 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-311 Caggiano.cloc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection D. Sy stem Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan).- Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------- ----------------------------------------- ------------------------------------------------ Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 08311 Caggiano.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown 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.): Tank is not in need of pumping at this time, tees are intact and clear and liquid level was found at bottom of 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 A Comments (on,pumping recommendations, inlet and outlet tee or baffle condition, structurai 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): 08-311 Caggiano.doc-08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 15 �\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Ca99 iano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box; etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-311 Caggiano.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owners Name information is required for Hyannis MA 02601 December 29, 2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 6 Infiltrators. ❑ 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.): Interior of infiltrators were video inspected and no standing water or signs of surcharge were observed. 08-311 Caggiano.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).- Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes [I No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions - Depth of solids r Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-311 Caggiano.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 . Commonwealth of Massachusetts r Title 5 Official Inspection Form - , Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Houghton Road Property Address Diane Ca iano Owner Owner's Name information is H annis MA 02601 December 29, 2008 required for -y ._ --- --- - -- -- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System. Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r\ \ •! /+ '' +• SFr.�y. ;:* '+ / 1 15 28 15 38 Water Service Houghton Road F ` ' a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M "• 5 Houghton Road Property Address Diane Caggiano Owner Owner's Name information is required for Hyannis MA 02601 December 29, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 10 + 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.- El Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain. You must describe how you established the high ground water elevation: Open water at rear of property is considerably lower than bottom of SAS. 08-311 Caggiano.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 -\ COMMONWEALTH OF MASSACHUSETTS+ EXECUTIVE OFFICE OF ENVIRONMENTAIJ. 9 �MRS`9'i`JTABLE DEPARTMENT OF ENVIRONMENTAL P�t9TMMObl 1: 42 ION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name• Owner's Address:,.' L� CIA C.�:�(oG l Date of Inspection L ( 2i r2.626J Name of Inspector_:,(please print)' Company NameCQP/Y1 �C. Mailing Address: f. 0f A-1A a&�� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.,I am a DEP approved system inspector pursuant to/Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F,ails� Inspector's Signature: //,l/ Date: c - L l The system inspector shall subi4ra 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. Notes and Comments ****This report only describes conditions at the time.of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 1� Date of Inspection:, , /'_M_(.-ew- 1 Inspection Summary: Check A,B,C,D or E. ALWAYS complete all of Section D A.-IV Passes: Y I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,.no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and,over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally-sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced . ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: ''2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: v -G' 1 Owner�`1"- °!9 r q l ("/r)A r• Date of Inspectiori\-QeA4 Al' C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any).determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has.a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply welt. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3. i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: Owner• a I ljo. Date of Inspectio f �, D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N — V 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 J cesspool . ILiquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped . Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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 coliform bacteria and volatile organic compounds indicates that the well is,free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria A0are triggered.A copy ofthe analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to cotrectthe failure. E: Large Systems: To be considered a large system the system must serve a facility with a,design.flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E.the system is considered a-significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310,CMR 15.304.The system owner should contact the appropriate regional office of the Department. 1 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: j Ia i OwJr`e/ Date of Inspection: i i .o; �2':,' Check if the following have been done.You must indicate"yes"or"no"as to each of the followins:' Yes No .Pump in-.information was provided by the owner, occupant, or Board of Health ZWere any of the system components pumped out in the previous two weeks ? / Has the system received normal flows in the previous two week period? v_ Have large volumes of water been introduced to the system recently or as part of this inspection? L/ 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 j Was the site inspected for signs of break out? V f f Were all system components, excluding the SAS, located on site? V _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: Yes ,no Existing information. For example,a plan at the Board of Health. _G_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM JNFORMATION Property P y Address: f1�.. �. G ,�c Owne�, 2t&d,q Date of Inspection.^' ,, , .!,cX ©S FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMI�1,5.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: ))/ c� Does residence have a garbage grinder(yes or no): :Ci Is laundry on a separate sewage system (yes or no)j�..[;If yes separate inspection required] Laundry system inspected(y js or no): Seasonal use:(yes or no):,/ b 6 Water meter readings, if available(last 2 years usage(� d)): j 3 Sump pump(yes or no):,/\ Last date of occupancy: p ( / <� � / `' g''` el_Llx� COMMERCIALANDUSTRIAL.A Q Type of establishment: Design flow(based on 310'CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping; .. _ TYPE OF SYSTEM __.�,,eeptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval , _Other(describe): A rox�at� ge of all components,date in tailed- ' known)and source of information: . Were sewage odors.detected when arriving at the site(yes or no)- b 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 G' '!:! &Lv, Owner. �"' .Date of Inspecon \ ,[;Fr �1. a3c BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comment '(On''Cnnd;tioP of.jo, ts, venting, evidence of leakage,etc.): SEPTIC TANK: V (locate on site plan) Depth below grade (.%✓ r� Cc7 Material of construction: concrete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /(`',)k XIs— Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ✓� Scum thickness: Distance from top of mucs o top of outlet tee or baffle: 7— Distance from bottom of scum to bottoni,.of outlet tee or baffle: IP 1 How were dimensions determined: ,.gip 1s ��/%C�- ihf,2�1 � Comments(on pumping recomme drric ationsklet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc) .r GREASE TRAP:� locate on site plan) 5 Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): 7 . Page 8 of I 1 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ram' SYSTEM INFORMATION(continued) Property Address: ;� Owne L J _1AIA41 _ l Date of Inspection: 0o 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:5 Comments(note if box is level and distribution to outlets e �al,any evidence of solids carryover,any evidence of iakage into or out of box;a .): � -• '� ( PUMP CHAMBER(locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): a Comments(note condition.of pump chamber,condition of pumps and appurtenances,etc.): o O Page 9 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) e r Property Address:. l� (' ,ee ` ~ / .� �)-ee- ra OwnAm )PIqj/If >r ( ,d ` Date of Inspection�f_ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type le g pits,its,number:_ � Reaching 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.) _ /� f f! ! �. .>t f, Ash (%_ I a r ' ) 5-— I 62 46 i `. 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 or no): . Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY.-4/0(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.):' 9, Page 10 of 11. OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: x Owne 'R&4,,r�yi � �rr Date of Inspectid r � � US SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. i 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner"- : . o Date of Inspection: "�� �.: 62/'�)0'� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �7—feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design.plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: i 11 _ Permit Number: Date: Completed by: 1 -- ':°-;:;• HIGH GROUND-WATER LEVEL COMPUTATION zi r Site Location: ✓ /Iep Lot No, Owner: Address: Contractor: Address: . y' Notes: STEP 1 Measure depth to water table F, to nearest 1/10 ft. ................... �L p✓ Z ........................ .Date ................... month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: t OA Appropriate index well............................. ,,,;,. i OWater-level range zone .................................. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ............ �.. month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ................................. �i STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ...............................:. ��� Figure 13.--Reproducible computation form. i5 S_ L 1.71 .. JJ .e - TOWN OF BARNSTABLE LOCATION G SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE N0,13C 4dQ SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /�Lrx-4 (size) 7'. t— NO. Of BEDROOMS PRIVATE WELL OgjPUBLIC WATER . BUILDER OR ! WNE DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No J a : `.game w •� ®� 73e Fss .. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Di-tipuittl Workii Towitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (JVQ an Individual Sewage Disposal System at: .. .... .. l°-�fJ cJ� 1 N Q rV 1 Location- lddress - o t No.� A ➢� Owner _ Address W .....�G� e.�`�l•._._......dv..................................... 4 Installer Address Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms-------- �-_.-_ _____-_____-_---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fix re d ----------------------------------------------------------- --_.------------------------------------------........_------ W Design Flow...................�_........-•--__gallons per person per day. Total daily flow.___.........y �..__gallons. WSeptic Tank—Liquid capacity _.gallons Length________________ Width____.____ Diameter---.------------ Depth___-________-_-- x Disposal Trench—No. ......./.......... Width...... -------- Total Length___ ��otal leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet-------r?�Total leaching area..................sq. ft. 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........................ fi Test Pit No. 2................minutes.per inch Depth of Test Pit__._____-.______-_-- Depth to ground water........................ P+ t-- - ._.. O Description of Soil-----------------------Q-- �'------------�--- ... --------'�°J V .------------------------•--------------•-•-------••---•--•------------------------------......--------------------------•----------••...•-------•-------------•--•---•--•----•--••......----•------•---- W .. U Nature of Repairs or Alterations—Answer wh pplicable.........:..... _....__._. ---e --__���_�-+------- / > / Agreement The undersigned agrees to install the afore�escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliays een iss the board of health. Signed ................................ .............................. �7 7 Dace Application Approved By .......:... ... .. ... /�'� i... Application Disapproved for the following rearont- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -- ----------------------------------------------------------------------------------------------- ---------'----------.............................----------....... ---------------------------------------- Due Permit No. ------- ;e4�.�..... --------- Issued ----- Dace Pip- ' Q i l,Z_5 No..................77� Fps:-Sid................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Bi-ripuittl Wurk,i Tomitrudinn rami# Application is hereby made for a Permit to Construct ( ) or Repair (b�) an Individual Sewage Disposal System at: .......�••---..._--•----• fir....... -•..............................•--•-•. --------------- rV i� --••------•--•-----•--•--•---•-----•------. Locatyon-Address or t No. �LJ� l3 .�i1 1 G� -- ..........................................................1/ � L-AZ54/ 7��1 ---------------- yc �stilr�J,t� -......_......-------•----. _,77Owner n . Address •••••-•----•••--...-•-••--•-•• ••-•••------•• ---•-•••. •------ ----------------------------- ----• ------.-••--•-------••--•------------..........-•---- Installer Address PQ d Type of Building Size Lot............................Sq. feet U -- Dwelling—No. of Bedrooms......_.N ____________---------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------------------------------------•---•-------•-------...-------••-----•--•-••-••••-••--•-•--•-•••-••-••-•--•--•-----•---• W Design Flow............... �-----------------gallons per person per day. Total daily flow............ ____gallons. WSeptic Tank—Liquid capacityW_.gallons Length________________ Widths_-_--.--. Diameter................ Depth................ x Disposal Trench—No. -------�__.._.___. Width......`__------ Total Length..-. !Total leaching area____________________sq. ft. Seepage Pit No...................... Diameter-------------....... Depth below inlet....... -Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- -----•---•---••••---•--•••--•-----------------------•-......•••-• Date-----------------------------------..... ,.a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----.--.._-___--..__.-. (Zq Test Pit No. 2................minutes,per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---•-------- -------- -----..-.----- .:�AA .....-----•-------- ---•-•--......................................................... ODescription of Soil r" a =5 -�----------------•----•----------...--------•----------------•-------• x W U Nature of Repairs or Alterations—Answer when applicable.____�/-j �_--1___�_-C-_--------2�y............/`7•L.-_ --•--�-i�Nl� � D d•.5.......�..__...... ... /•'�'� �._C T "fJ•!Z�-•----.....1 . .... .-•-- Agreement: The undersigned agrees to install the a fore described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliancerr%1as peen isssJe y the board of health. Signed I�� --- � .. �� .... � Dace Application Approved By .......... ..�'✓.� ,' Dae Application Disapproved for the following reasons: ............................................................................................. .................................. . ..... ......................................................... ...................................... ....... .... ._..... ........................................Dve Permit No. - :........ ..��. --- - ----- - Issued ....... �+�.`... Y.0r_4.._ Dace ------------------ ---------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (gez#tf rate of C�IImyiianre THIS IS TO CERTIFY _T.h.at t Indl� victual Sewage Disposal System constructed ( ) or Repaired ( ) G > ��i.t 1.... ------- s'����.� --------------------------------- bY ... -- - Inst:]I - 11N�1►Vt S ....... ... ..--------l /.U�C ?`U/ --------------------------------------------- has been installed in accordance with the provisions of TITIS of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... .. --06EVAS `�_4. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B`E C0_o A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. x, ... ./--j DATE......... ... Inspector- ......��t-az,. f --------------------------------------------- I 1" _3L '?i✓� THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH 9 TOWN OF BARNSTABLE i n ttl nr� To fr tinn ramit Permissionis hereby granted-------------------_--- ✓......_.0 c G...-... G -........................................................ to Construct ( ) or Repair 0,/) an Individual Sewage Disposal System at No. v ••--•-••f iJtJfw��T__GN-- --------�-......:......`..-���oVr�ls------.....----•-............ Strce as shown on the application for Disposal Works Construction Permit � ated__!-__,+r_"'. � T -----.............. Board 51 f Health / DATE...... / j ------------------- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS