HomeMy WebLinkAbout0371 IYANNOUGH ROAD/RTE 28 - Health 37,,1`Iyannough Rd/Rt. 28
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__VII.LAGE '24 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&.PHONE NO.
SEPTIC TANK CAPACITY 4"111
LEACHING FACILITY: (type) Le"f c : .'45 (size) 2
NO.OF BEDROOMS G✓0 -1 �— Q (�
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet off,leeaching facility / Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z
,M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. City/Town State Zip Code Date of Inspection co
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, "%"OFrMgs4i����
use only the tab 1. Inspector:
key to move your p?• •.yG%
cursor-do not James D.Sears = JAMES m
kee the return Name of Inspector =cj; SEARS
y * _
Capewide Enterprises, LLC =
- -
Company Name i RT I O�`
153 Commercial Street F s N*iP
Company Address
uff 0-1
few Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title,5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3-18-16
spector'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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page
/1�of 17
/ag,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
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:
The system is a 1000 Gal.Tank D Box and two pits.
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):
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
°M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown 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 Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
I
❑ 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is
required for every Hyannis MA 02601 3-18-16
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 is less than 6" below invert or available volume is less
than '/2 day flow /0/TS
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
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?
❑ N 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): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•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
LM , 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is
required for every Hyannis MA 02601 3-18-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and two pits.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) El Yes El No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: Ware House Stores Bays
Design flow(based on 310 CMR 15.203): NA
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): NA
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: NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is
required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 2015
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
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:
1986 Permit #86-292 3-2016 New D Box
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 34"
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):
2'
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: 1000 Gal. Precast H 20
Sludge depth: NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is
required for every Hyannis MA 02601 3-18-16
page. Cityrrown 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 NA
Scum thickness
1"
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
How were dimensions determined? Asbuilt-Tape
Past Report
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 at working level. In and outlet baffle. In cover steel at grade. Outlet cover under black top.
No sign of leakage.
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. CityrTown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown 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 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 new 3-2016. H-20 box w/two lines out. Steel cover at grade in black top area.
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM s 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
I
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two H-20 precast pit's w/steel cover's at grade. Pit on left full. Pit on right dry like
new..
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
379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•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
,M s 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�- zz (9
)1
3
3 �
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N0
Estimated depth to high ground water: 2
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per past report 24.5'+ to G.W..
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 379 lyanough Road (Rear BLDG)
Property Address
lyanough Realty Trust
Owner Owner's Name
information is required for every Hyannis MA 02601 3-18-16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Town of Barnstable Geographic Information System March 25,2016
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DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:328 Parcel:230 ® N
Owner:MATHEWSON,WILFRED B& Total Assessed Value:$710600
boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel
1"-100'may not meet established map accuracy standards. The parcel lines on this map W E
are only graphic representations of Assessor's tax parcels. They are not true property Co-oOwner:IYANOUGH REALTY TRUST Acreage:1.16 acres Abutters r?.;; j
boundaries and do not represent accurate relationships to physical features on the map Location:371 IYANNOUGH ROAD/RTE 28
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such as building locations. Buffer ,�
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COMMONWEAL'I'lI OF MASSACIIUSE'I"1'S
=_ EXECUTIVE OFFICE OF ENVIRONMENTAi, AFFAIRS
UI;I'AR'1'M1 N'1' OF 'NWRONNI W'1'AI, PRO'1'I:C'1'[ON
&
ONE WINTER STREET, BOSTON MA 02109 (617) 292.5500 �
J�gQ
TRUDY COXF
` Secretnry
350 MAIN STREET
'`ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVID B. STRUIiS
Governor 508-775-2800 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 292 PAR 080
PROPERTY ADDRESS: 379 IYANOUGH ROAD, HYANNIS ADDRESS OF OWNER:
DATE OF INSPECTION: MARCH 1, 1999 IYANOUGH REALTY TRUST
NAME OF INSPECTOR : JAMES D. SEARS REAR SYSTEM
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A 8 B Canco
%MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: MARCH 3, 1999
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:
revised 9/2/98
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
µ '
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
B SYSTEM CONDITIONALLY PASSES:
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
system,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
D]SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
N/A I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
Significant threat to public health and safety and the environment because one or more of the following conditions exist:
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
N/A Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
s.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms(design) Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): If yes,separate inspection required
Laundry system inspected(yes or no):
Seasonal use(yes or no)
Water meter readings,if available(last two(2)year usage(gpd):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment: WAREHOUSE&STORE
Design flow: N/A Gpd(Based on 15.203)
Basis of design flow N/A
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no) NO
Non-sanitary waste discharged to the Title 5 system:(yes or no) NO
Water meter readings,if available: N/A
Last date of occupancy: N/A
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no)
If yes,volume pumped: Gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information:
1986 PERMIT#86/292
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
h
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan)
Depth below grade: 2'
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: l C o o F pL
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,,etc.)
IN&OUTLETS HAVE BAFFLES IN PLACE INLET AND CENTER HAVE 2'STEEL COVERS AT GRADE TANK AT WORKING
LEVEL.
GREASE TRAP: N/A
(locate on site plan)
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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
-Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: p
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-BOX IS 30"X30",28"BELOW GRADE,ONE IN,TWO OUT.BOX IS CLEAN LEVEL&SOLID.
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 2
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
TWO(2)1,000 GALLON PRE CAST PITS BOTH ARE 50"BELOW GRADE 2'STEEL COVER AT GRADE BOTH PITS HAVE 12"
WATER,NO HIGH WATER MARK.
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
r
d
o
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated.Depth to groundwater 24.5 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
USGS 1-99, WELL DATA AIW 230, ZONE C.
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revised 9/2/98 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART
CERTIFICATION
MAP 2Q2 PAR O8O
PROPERTY ADDRESS: 37g |YANOUGH ROAD, HY/\Nm|S ADDRESS OFOWNER:
DATE OFINSPECTION: MARCH 1. 199S |YAN[>UGH REALTY TRUST
NAME OF INSPECTOR : J4K0ESD. SEARS FRONT SYSTEM
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
` COMPANY NAME: A
Mx|umG AoonEsa: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER:CERTIFICATION STATEMENT
}certify that|have personally inspected the sewage disposal aystem at this address and that the information reported below is true,
accurate and complete asor the time ofinspection. The inspection was performed based onmy training and experiencein the proper
function and maintenance v,on-site sewage disposal systems. The system:
X PAouss
CONDITIONALLY PASSES
----' NEEDS FURTHER EVALUATION av THE LOCAL APPROVING AUTHORITY
FAILS
/
INSPECTORS SIGNATURE: DATE: MARCH 3,1999 �
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty pO �
days of completing this innpeoVnn. If the system isa shared system vr has o design flow nf1O.Oongpdn,g,pate, memupemo,and t''^
sy�emowner nhonsubmit mpmpn�mmeappmp,i�e�givna|o� m cev, eDepo�mnntvfsnvimnmento|Pnxpmi'-n The original
should besent tn the�etemowner and copies sent m the b�er.|fapponob|n and moappm�ngamhv,ity. �
NOTES AND COMMENTS: �
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revised 9/2/98
-
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
B SYSTEM CONDITIONALLY PASSES:
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
system,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
i
I
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
D]SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
N/A 1 have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms(design) Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): If yes,,separate inspection required
Laundry system inspected(yes or no):
Seasonal use(yes or no)
Water meter readings,if available(last two(2)year usage(gpd):
Sump Pump(yes or no):
Last date of occupancy:
COM M ERCIAL/INDUSTRIAL:
Type of establishment: BANK&STORES
Design flow: N/A Gpd(Based on 16.203)
Basis of design flow N/A
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no) NO
Non-sanitary waste discharged to the Title 5 system:(yes or no) NO
Water meter readings,if available: N/A
Last date of occupancy: N/A
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1998 BARNSTABLE PLANT
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: Gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information:
UNKNOWN
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan)
Depth below grade: 32"
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: N/A*
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: N/A*
Distance from bottom of scum to bottom of outlet tee or baffle: N/A*
How dimensions were determined TAPE
*NOTE:OUTLET COVER UNDER BLACK TOP..
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
INLET BAFFLE,INLET COVER T STEEL AT GRADE,TANK AT WORKING LEVEL.
GREASE TRAP: N/A
(locate on site plan)
i
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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: N/A
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C �
SYSTEM INFORMATION (continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number:
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number, 3
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
POOL#1 OUTLET TEE,AT LEVEL OF OUTLET,BLOCK 10'DEEP 2'STEEL COVER
POOL#2 NO OUTLET 11'DEEP 2'STEEL COVER 2"WATER BLOCK
POOL#3 NO OUTLET 10'DEEP 2'STEEL COVER 3"WATER BLOCK
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
�oNr
\9'
5� 1at 94�
0 s7 c 0a
A
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 379 IYANOUGH ROAD, HYANNIS
t
Owner: IYANOUGH REALTY TRUST
Date of Inspection: MARCH 1, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 24.5 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
USGS 1-99, WELL DATA AIW 230, ZONE C.
revised 9/2/98 11
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
BOARD OF HEALTH O Satisfactory 2.Printers
3.Auto Body Shops
IN,
4.Manufacturers
NY COMPA Crej"dt CoZiizO f \(see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS Dall Ed. Class: 7.Miscellaneous
Q ANTITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALS
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline Jet Fuel(A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil(C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous: d�
DISPOSAL/RECLAMATION REMARKS: n
1. Sanitary Sewage 2.Water Supply kl_`C," C"I k4dyy
O Town Sewer public C41V(d Llci 6.9 r ® (Al"
On-site OPrivate vk�C) f J
3. Indoor Floor Drains YES--NO-4-
0 Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO 017 RS:
O Holding tank:MDC •M S 6) v e
O Catch basin/Dry well C)1� �r� �� �' 'f
KL On-site system
5.Waste Transporter
'PrName of Hauler Desti te;
o Ucens• �
YES N0
1.
2. r
— 4,9
V41UL, 01
er on(s) Interviewed Inspector D to
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
0 unsatisfactory- 4.Manufacturers
COMPANY 4a c V,/.t AJI� (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDREWf 9r Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
DISPOSALIRECLAMATION REMARKS:
1. Sanitary Sewage 2.W4ter Supply
O Town Sewer ®`Public
0 On-site OPrivate PAq
3. Indoor Floor Drains YES NO
0 Holding tank:MDC_
0 Catch basin/Dry well
0 On-site system
4. Outdoor Surface drains:YES !f NO ORDERS:
0 Holding tank:MDC
Catch basin/Dry well �/fJ
0 On-site system
5.Waste Transporter
MINIMS
YES NO
2.
/,(AAM
Person(s) Inte Mewed Inspector Date
TOXIC AND HAZARDOUS MATERIALS R GISTRATION FORM
NAME OF BUSINESS: 6L-OeAL -i'r,,tC-1Dk, Mail To:
BUSINESS LOCATION: `3?r ll*jI-r.$ Board of Health
Town of Barnstable
MAILING ADDRESS: R%(*tPJw+S , .-55 ®Z(Vo I P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON: OogmAm) W&K&C:5
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES jiff NO Sow -cT'wnf-S (w*-s,E 0 o L)
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel 17656-4eeOwl)5' Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
J' Car wash detergents 1 cvOQ.I Lye or caustic soda
Car waxes and.polishes II cAt Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, ep4hesle'stt ins, dyes /-xa c,4,Js Fertilizers (if stored outdoors)
Paint & lacquer thinners I ca14 PCB's
Paint& varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products,not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents, '
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business .
• F f
1
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
2. nters
BOARD OF HEALTH O satisfactory 3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY �^ 'AAA (see"Orders") 5.Retail Stores
//NN 6.Fuel Suppliers
ADDRESS �t/C� N IBss' 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT-outdoors)
MAJOR ERIAL Case lots Drums
IN OUT IN OUT IN OUT #&gallons Age Test
'b^
Gasoline, et Fuel(A)
Diesel, Kerosene, #2 (B)
Heav
waste motor of
e � <01
motoroil
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
Gv _' ,��
Q
t '
CAS
DISPOSAI✓RE(;LAMATION REMARKS:
d
1. Sanitary Sewage 2. ater Supply ° 0,10(9 tA V �es ioo
O Town Sewer Public
O On-site OPrivate
3. Indoor Floor Drains YES NO
)L
O Holding tank:MDC
O Catch basin/Dry well
0 On-site system
4. Outdoor Surface drains:YES NO ORDE Sr ff// //
O Holding tank: MDC V� wA rg o C'
O Catch basin/Dry well v 1 S14ozV I
O On-site system
5. Waste Transporter
Name of Hauler Destination Waste Product
4YENO
1.
2. /
Per on (s) Interview/
nterview d Inspect
TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
Z_Ysatisfactory 2.Printers
BOARD OF HEALTH 0 3.Auto Body Shops
�J unsatisfactory- 4.Manufacturers
COMPANYe+1�S-7—A4 4 A 6 (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS 177R� 14/u41WS4 Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS lots . fidero-ound'Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline Jet Fuel(A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
P
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply ,
0 Town Sewer Public
Von-site OPrivate
3. Indoor Floor Drains YES N0_P_
O Holding tank:MDC ,
6
0 Catch basin/Dry well ae
0 On-site system /'
4. Outdoor Surface drains:YES 6� NO ORDE S:
0 Holding tank:MDC
0 Catch basin/Dry well
0 On-site system
5.Waste Transporter
MUM
1.
2.
Person(s) Interviewed Inspector Da Ke
772
TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory
BOARD OF HEALTH 2.Printers3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY / (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS ' , k � ass• 7.Miscellaneous
3-V Q T_ ITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALS Underground
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
I
DISPOSALJRECLAMATION EMARKS:
1. Sanitary Sewage 2.Water Supply ®�S
Town Sewer Wublic `$
O On-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
p Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES_r,_NO O ERS:
O Holding tank:MDC
`Catch basin/Dry well
0 On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO �
1. I
2.
L N14"
iiii Person 0Interviewed Inspe for r Date
yo
�J,
TOXIC AND HAZARDOUS :MATERIALS REGISTRATION FORM
NAME OF BUSINESS: I " �li I��� 1� 1 �C:'j Mail To:
BUSINESS LOCATION: oe> , Board of Health
Town of Barnstable
MAILING ADDRESS: P.O. Box 534
TELEPHONE NUMBER: 7/— 41 Hyannis MA 02601
CONTACT PERSON: l4'Ti�° y�Qf� t.
EMERGENCY CONTACT TELEPHONE NUMBER: a
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, _ _ _
YES ,NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.If you,answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid )K _ Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants -�
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
_ Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) ~
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
—X Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
t'
White Copy-Health Department/ Canary Copy-Business
o: .
• k
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
BOARD OF HEALTH
satisfactory 2.Printers
3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY 0 .6d �S�L 5 6.Fuel Suppliers
/" (see"Orders") 5.Retail Stores
ADDRESS ') 7F-Z,—n2,W u w+3 S-4 Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Caselots Drums, A60ve Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline Jet Fuel(A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil(C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
l
Miscellaneous: l610 9�
S /D Pa-A---+1__14VV'_
q c
c °
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply � '� `' r, � liG,-lp1 /4.11
O Town Sewer j5Public
WOn-site QPrivate CLS ��•�
3. Indoor Floor Drains YES NO
O Holding tank:MDC_ S
O Catch basin/Dry well
0 On-site system _A keA,4 r �rf
4. Outdoor Surface drains:YESYNO ORDERS:
0 Holding tank:MDC 0 &7tLC, et(/ A4S DJ YG e7f-
0 Catch basin/Dry well 4pvv-,L , v4._4v4rO 6-,r r vet r1Tp� �evc,
Won-site system
5.Waste Transporter
Name of Hauler De tinaii6d'
q
YES NO
1.
2.
rson(s) Interviewed Inspect r Da e
YY /7 ( dA014'��F�BARNSTABLE
LOCATION ;, ,IV � 1 WAGE # Ao
VILLAGE ASSESSO 'S MAP & LOT
INSTALLER'S NAME & PHONE NO. \ ,f
SEPTIC TANK CAPACITY �G% ✓�' `'�i 1
LEACHING FACILITY:(tyl)2? ?v-lcjloJ (size) at+ ----
NO. OF BEDROOMS PRIVATE LL OR PUBLIC WATER
BUILDER OR OWNE � � �J
DATE PERMIT ISSUED: /
DATE .COMPLIANCE ISSUED: ZLI-
VARIANCE GRANTED: Yes No ��
"�— �
�- ,,
..;� v �;
_�
� � r
� �` � �
,U \�
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No---------------- .._. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...----...�Ow»................._0F...Rar447W2,.......................................................
Appliration for Uhip titt1 Works Tomitrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair 44) an Individual Sewage Disposal
System at:
ir-A
�f�..... is......... ......•------------------_-_-_--•--------------------r-------------------------------•-----------
ocation- dr ss t T
;LrR►• I rua + � sans��....:. .4....................... _.�'�t.!_��. _' .. s�... Q!'1!�3
Owner Addr s _
p n -------------•- ''11--•---..........-•----
W .. ----------------------•--...__........... ..�.�Fl.'a_�1�cc.in ...�t6...d�1C�QWC!�
Instalier Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons................_----------- Showers — Cafeteria
Q' Other fixtures -------------------•----------•- -
W Design Flow............................................gallons per person per day. Total daily flow_...........................................gallons.
P4 Septic Tank—Liquid capacity___.._._____gallons Length________________ Width___.____.____.._ Diameter__-_ ________ Depth........ ._--
Disposal Trench No._. _______________ Width.................... Total Length.............._..... Total leachingarea....................s...ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) -
~' Percolation Test Results Performed b _________________________________________ Date...................._...................
.a 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.......................................................................................................................................................................
W -----•-----•---------•---------------••-•-•••-•-•-•••------•---------•-------------•-------••-••--•----•--•••--•---- ------................. -------------•------•-••
U Natur of Repairs or Altera ions—Answer when applicable_1 a .` s+?�_ ____1_00w -_1 1I?� ______.___.
Agreement: C
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T'L is 5 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 he lthSign .
ed--------- ...........:- ----
Date
A -------------Approved B
PP PP Y = = = ..._-----••-•--- ------------�------------------••-•---
Date
Application Disapproved for the following reasons:..............................................................................................................
-•-•-•---••----------•-----------------•---------------------•---•--------•-----------......------------•.__....--•-------------------------------------------------------•----•---•----•-••-•-----------
-�y Dat
rae
PermitNo............•• 9-------__-- Issued.......................................................
Date
' N �..�Z�� j F>m$......1 L.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{"�,.> OF .....------•--•-••......................................
r
Appliration for Dispniial Works Tnnitrnrtiun ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ()4 ) an Individual Sewage Disposal
System at: {
.i..,. ..... .�,
....:----- � ......._...-•-- --.-......---�--------tip•---•---•-----....
�- .1 ' or Lot No.Location-Address { f
C uS _. f `+,nOwner._ ._._.... ' ..-1._..t« l..0.•.rr. .. . �l,sG t111:,
P �uske4 c - - -
} Address � 1
orr•.r" _l S lr,'a 1.1 J�S c7' �!,)Gr
Installer Addressv
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...........................................:Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
A4 Other fixtures ----------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter------------.--- Depth................
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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit..........._........ Depth to ground water--___-_____-_-_------_--
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------••---------------------------...................-•----....-•---•--........................................................
0 Description of Soil........................................................................................................................................................................
x
U -•----•----••---•---••-•-••-•-•••••--••------•--•---••-•-••••••---•-•----•--•-••---•---------•-•••••----•--•-•-•----•-•-----••-•--•--•••------------•---••---•-•••---------•---------------------•----•.
UNature of Repairs or Alterations—Answer when applicable.:L- i.-.�=.� "��_ '_- �'�._._ ""�.?. ...................�' r t '*-`: __
` r ---
Agreement
J
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of 1i �.: 5 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.
• --..:_.._..-••-•-•--• ..........................-----
�, / (,�/��� ` Date
� . 1 YI^ 4.L = �e
Application Approved B .....................
Date
Application Disapproved for the following reasons:....................................................................................--........................
-
---•-••---•----•••--•--•••....-••------••-•----•---•-••-••-•---•---------•------•-----•-----••-•......---•----•-•------••-•----••••-----•---•----•---------------------••-----••---•--•----------•-----
Date
PermitNo..... .......-�h.. -. Issued_.......................................................
Date
d4 4 5 4 THE COMMONWEALTH OF MASSACHUSETTS
11 BOARD OF HEALTH
lJr —�J(e1Y1..................OF....17.', ¢ .i��r�V�EL
....................... r . . ........................................................
Turrfifiratr of Toutpliatta
TISM Q FIIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby.. . .......----•-. --•-•--•-----•--•-....-----•--------------•----------•-----•••-••-----•-----. -•-----..... ..........................................................
Ic Installer
at......... -------;�105:41_
has been installed in accordance with the provisions of rLKE 5 of The State anitary Code d •cribed in the
application for Disposal Works Construction Permit No..'S`....._.I2��._. dal 2._�.__ ��_�................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............. .................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OFt HEALTH
�•_•�- f �aCfl�11 ._OF..... �.................................... ...
NO Z FEE.......................
1hoplaiialRNO
rkii Qxnotr on rrmi#
Permission is hereby granted.......t - ----•------------------------------•-------------------------.-.-...--.--------------•----•-•----.-•-•-
to Construct ( ) or ( ) an Individual Sewage Did sal System
�/ .........• ••--•-........ •
Crt
Street � /L' �j
PPDisposal ---- Date ----- ---------------.(•.�----�---...._.. ,
as shown on the application for ���orks Construction Permit No.._.__.�:__- �� ^ A
Board of Health
DATE.................. = ...............................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS