The URL can be used to link to this page

Home My WebLink About0032 KEEL WAY - Health 2:- EEIs WAY, HYANNIS A=, t ° 17 ° t it ° 1� ` W Y -,.• .: - _ TOWN OF BARNSTABLE LOCATION 3a 1 et, WAS SEWAGE # VILLAGE NTtAlmts ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY GQ sSRop LEACHING FACILITY: (type) (�SSp�� (size) NO. OF BEDROOMS BUILDER OR OWNER RC A CU ker PERMTTDATE: COMPLIANCE DATE: ZBz�� Separation Distance Between the: G 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 19 C.,`9 .s. i CD d t� � ) 1. t 4 C y - S� No. -7 9 Fee VD THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 9pplitatfon for MIspoBal &pstem Construction permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 32 Kcci Way 4yontn0i$ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0!o pro L t f 1 I P i(7rJ Ux I Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms iv 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 N` �{ 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) 6� Liter c bezwea ltl • /JP (e A `` N. 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 `n y r Application Approved by ►V` , Date 7 Application Disapproved by Date for the following reasons Permit No. V-M Date Issued -------------------------------------------- -------- -- ---------------- --- - ------ lr .....rv:K:�W(� '`a'�h"� ii�'t�'�"•iP`..-.o.•�.k�.r'r�r,�nwr�•.�i��t's�'�,i�'+rRz�V".+r +a++...,,,r,,,,.,ti�„isA.T�Qi��v:}��y �t��.." •:4sii`,Y}+V, tiSa°y�bTf�•'.,2{�`'ix3:+tRsFR7�'ti.au .r-c.w; Fees +.> THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: S PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpphratlon for ]Disposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f}70n S Owner's Name,Address,and Tel.No. Assessor's b4ap/Parcel a(0 9 w f}i p fO,5 velly Installer's Name,Address,and el.No. Designer's Name,Address,and Tel.No. T . c i =ac 5 -4 9.0 N Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other_ Type of-Buildirrg No.of Persons Showers( ) Cafeteria( ) "- -- -Ofher Fixtures Design Flow(min:`required) N gpd Design flow provided gpd •-:.Plan Date Number of sheets Revision bate Title iyMr Size of Septic Tank '' Type of S.A.S. Description of Soil . ,..- Nature of Repairs or Alterations(Answer when applicable) J L G I P 1 ., Date last inspected: e" r ,q Agreement: x. s 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. nSiigned 4 Date Application Approved by Y VC` �xDate Application Disapproved by f` Date for the following reasons Permit No. Date Issued 7 �) r THE COMMONWEALTH OF MASSACHUSETTS x BARNSTABLE,MASSACHUSETTS y i V t AePO V ON 11 ' Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) r_ Abandoned( )by �2 1C emk{_ �tyay.�c A lJI QdY,I ,l noC at It nt �Tcmt�,�s� � - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit,No. 61 dated u� ("7 L— Installer Brpo�xx Designer #bedrooms t i� , Approved design flow �' gpd The issuance of this permi shall t be construed as a guarantee that the system will ctio rdesigne r Date o q Inspector Aes i17 Feer=-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS ]Disposal *pstem Construction 3permit Permission.is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 2 le Pvi (,J[+,�r9MC1N)t S_ and as described in the above Application for Disposal System Construction.Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date /a `( � ) 9 Approved by I i U.S. Postal gervice�- Domestic Mail Only r-q 43� Certified Mail e F F I C 1 A L UEr S A $ 03 \ � Extra Services&Fees(check box add fee as approp 2$29 3 7 ❑Return Receipt(hanicopy) $rq -(c1 O El Return Receipt(electronic) $ Postmark O ❑Ceruged Mail Restricted Delivery $ �- �tQ' Here t ', O []Adult Signature Required $ Adult Signature Restricted DellJery$ ry- IZI N CO LITTLETON,•KELLY. 24 CARRIE LEE'S V�b&lr �vd C3 CENTER VILL V1A'026,32tizVl ' Certified Mail service provides the following benefits:- n A receipt(this portion of the Certified Mail IabeQ. for an electronic return receipt,see a retail a A unique Identifier for your mailpiece: associate for assistance.To receive a duplicate n Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the' e A record of delivery(including the reciplerd's retail associate. signature)that is retained by the Postal Service" Restricted delivery service,which provides c!T for a specified period. delivery to the addressee specified by name,Or- Important Reminders. to the addressee's authorized agent C10 Adult signature service,which requires the ih a You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). - or Priority Mail®service. Adult signature restricted delivery service,which a Certified Mail service is not available for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified u Insurance coverage Is notavailable for purchase by name,or to the addressee's authorized agenu with•Certifted Mail service.However,the purchase (not available at retail). C3 of Certified Mall service does not change the ra To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should beara� certain Priority Mail items. • I USPS postmark.If you would like a postmark on ■For an additional fee,and with.a proper this Certified Mail receipt,please present your r3 bndorsement on the mailplece,you may request 'Certified Mail item at a Post Office"for — T� the following services: r postmarking.If you don't need a postmark on this '-Return,receipt service,which provides a record._.Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply � 1 ,You.can request a hardcopy return receipt or an appropriate postage,and deposit the ma 1piece. electronic version.For a hardcopy return receipt iy complete PS Fonn 3811,DomeOc Return t 'Receiphattach PS Florin 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. Ps Form 3400,April 2015(Reverse)PSN 7530-020*9047 ' and3. Signature ■ Complete item!"1,-2 • Print your name and address on the reverse El Agent so that we can return the card to you. - 11 Addressee • Attach this card to the back of the mailpiece, ved b rinted Name) C. Date of Delivery or on the front if space permits. a .dress.'1 0 Yes deli ery a dr=be No ��Y LITTLETON, KELLY P -24 CARRIE,LEE"S WAY 0 CENTERVILLE. MA 02632 47 Service Type 0 Priority Mail Express® 0 Adult Signature 0 Registered MaiITM dult Signature Restricted Delivery 0 Registered Mail Restricted Certified Mail® Delivery C 9590 9402 4798 8344 8737 66 Fccertifled Majl,Restricted Delivery Return Receipt for ._Q-C.ollect-on.Delivery Ilverchandise Artinlq delivery 0 Signature ConfirrnationTM 2 Restricted Delivery 'b011��4988;�*,kl841"��.i��,,j il 0 Signature Confirmation sk U-73 0 1 Restricted Delivery Restricted Delivery r (over$500) ,PS Form 381 1;July2015 PS.N 753 0-02-000-9053 Domestic Return Receipt used }� #RN ' I r } I, First-Class Mail ` Postage&Fees Paid USPS Permit No.G-10 9590 9402 4798 8344 8737 66 United States °Sender:Please print your name,address,and ZIP+4®in this box•• + w Postal Service Town of Barnstable i Health Division 200 Main Street .' Hyannis,i'v1A 02601 's !i i , ,�I i �ii�1,i"siill"i'ldill'ilil�'llijii,i,i'l�'ii''lli;'riiiil�ii:►liiii�i '- of THE � Town of Barnstable Barnstable Inspectional Services j iftaC•j p + BARNS7ABLE, ' "A� Public Health Division r�Dt"Ay� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL47015 1730 0001 4988 1241 June 26, 2019 LITTLETON, KELLY P 24 CARRIE LEE'S WAY CENTERVILLE. MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 32 Keel Way, Hyannis, MA was inspected on 05/31/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The septic line needs to be replaced. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\32 Keel Way Hyannis.doc Town of Barnstable • MUMSTABLF, Inspectional Services Department TED N4A'�� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-8624644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 i DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OIHER Repair deadline: I fOeAi(' Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc II/P 7-6�-a-a9 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owners Name information is required for every Hyannis MA 02601 5-31-19 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. N``01%11,,,,,,111,// OF Mq ii�i Important:Whenqc filling out forms A. Inspector Information off: on the computer, JAMES N use only the tab James D.Sears =A.: c177 A oS m' key to move your Name of Inspector Q :'n cursor-do not Jim The Inspector Man ` yv *�•.,� moo: use the return Company Name ! key. P.O.Box 784 , �St I N StpEVODG`\\�� „� Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-364-4398 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6-1-19 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. 1) 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: Conn Pass line change. The system is two block pools 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. I ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Need to replace line main pool to over flow. May be able to change part of line. ❑ 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): - 3) 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. a. 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: t5insp.doc•rev.7/2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: r ' 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No AIA ❑ ❑ 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 1/z 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 5) 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 CA. 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 15insp.doc•rev.7/28/2011 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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 1111111PEXIM manholes uncovered, opened, and the interior inspected for the condition of the 993=11 tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form .i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w � 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Two Block Pools. Number of current residents: 2 Does residence have a garbage grinder? ❑.Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d na 9. ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (copt.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to:- 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 I Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 500 Gal gallons How was quantity pumped determined? Gage on Pump Truck Reason for pumping: Part of inspection t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 C\ Commonwealth of Massachusetts IF Title 5 Official Inspection Form .a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis �L! Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): •Depth below grade: 32"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. and orange burge.Line Main pool to Over Flow need to change Line . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !y' 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is Hyannis MA 02601 5-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 6. Septic Tank (locate on site plan): 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 i Dimensions: 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 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Y e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Keel Way Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every �H annis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - - � 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): i If SAS not located, explain why: Type: ❑ leaching pits, number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool , number: 1 . ❑ innovative/alternative system Type/name of technology: t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way,Hyannis v Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a old Block Pool. 9' Deep w/30"cement cover at 10". 30"water in pool. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 4„ Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer 2" i Dimensions of cesspool 5'-7" Deep Materials of construction Old Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool 8'-7" Deep w/cover plastic At Grade pool at working level w/in and outlet tee's. Need to replace outlet tee and outlet line. May be able to change first part of line . l5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Keel Way Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N u 23' Estimated depth tcVFiigh ground water: feet Please indicate all methods used to determine the high ground water elevation: i ❑ 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: Past Report ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: I You must describe how you established the high ground water elevation: G.W.234. Bottom of over flow at 9' below grade. Bottom of over flow at 1 V above G.W. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 32 Keel Way,Hyannis Property Address Kelly Littleton Owner Owner's Name information is required for every Hyannis MA 02601 5-31-19 - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3,-or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included . r O ADE, 3 q . • i Gam, t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 YOU WISH TO OPEN"A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME In town.(wNch you. must do by M.G.L.-it does not give you permission to operate.) You mustfirst obtain the necessary signatures on this'form'at 200 Main St:, Hyannis, Take the completed form to the Town Clerk's Office.'.1st FI-., 367 Main St., Hyannis, MA 02601 (Town'Hall) and get"the Business Certificate that is required by law. -77 .. R'anp>�r ;td-'i� �'_, DATE:r(pZ"�5'15 Fill in'please: n N.w., y APPLICANT'S YOUR NAME%S: Jesvil W, t BUSINESS YOUR HOME ADDRESS: -a /ed / // • �C.i,'86r;PSZ �: S 3 /l / /VG�� 17 i�tA�1 TELEPHONE # Home Telephone Number 775� :.:-.. NAME OF CORPORATION. t r., • - ``' NAME.OF NEW BUSINESS,.t.��.1 • • {. N� dy.,��. Sz.r:. . •.•.• ' + . TYPE.OF:BUSINESS:. /�4'd't/iti�aH'.: ES.. , ...- .... . . .. ..... ... . .<,. -.. •=r> ��°�.�.. -A H M UPATIOIV. Y O � <, ADDRESS.OE BUSINESS... .. .: ._....�.... .:.....,:...... , ... .: .... . _ .. 11.,,.MAF .PARCEL;N IViBER ai ssessi•r' When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town•of Barnstable. This form is intended to assist you in obtaining the information you.may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. &Main Street) to.make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO MISSIO ER'S OF CE This individ al ha e n--Wor o- a per- it a uirements tha pertain to this type of business: . MUST COMPLY WITH HOME OCCUPATION' Aut on Si natiTr RULES AND REGULATIONS. FA1LURE•.TO ::. c M EN — COMP .Y MAY RESULT IN •FI.NES, t 2. BOARD OF HE LT This individual has been informed of the permit require, ents that pertain to this type of business. 1-2 . is Authorized Sight e'er COMMENTS: ,� �. . :HATARDOUS MATE T ALS I GUL TION$. 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. .Authorized Signature** COMMENTS: I Date:cs/-'a / aois. TOWN OF BARNSTABLE I, TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Ze Aoj se .Se-vice BUSINESS LOCATION: .3a Feel klAy //yam,,,f !!& W ki INVENTORY MAILING ADDRESS: 3a /(eel La/y 11G ,» /"w r chi TOTAL AMOUNT- TELEPHONE NUMBER: 7,1-yy7-8393 CONTACT PERSON: �Asyi '44-Se EMERGENCY CONTACT TELEPHONE NUMBER: 77/f47-8393 MSDS ON SITE? TYPE OF BUSINESS: H9r�yl�11�1h INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a.license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye,or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes ee// Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials r COMMONWEALTH OF MASSACHUSETTS 9 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS- *E-O DEPARTMENT ✓OF ENVIRONMENTAL PROTECTION UN ONE WINTER STREET, BOSTON MA 02108 (617)292 5500 6 t TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 32 Keel Way, Hyannis, MA Name of Owner: Reba Cuker Address of Owner:. 70 Center Street,Apt. 4 Date of Inspection: June 14, 2000 Brookline, MA 02446 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 268 Telephone Number: (508)862-9400 Parcel. 209 Lot. 32 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: ✓ Passes Conditionally Passes Needs Further Eval on By the Local Approving Authority _ )sub Inspector's Signature: Date: June 15, 2000 The System Inspector shalracopy of this' pection 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 Page 1of11 �- Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) r •t� .. C Property Address: 32 Keel Way, Hyannis, MA Owner: Reba Cuker Date of Inspection: June 14, 2000 :�; c :.s. 7s ;:;:. c�.•,i'. . �, ', i INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: A'. 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. ; Indicate yes, no,or not determined(Y,N,or ND). Deicribe 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 t the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank. '• `" failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 'Se*ag6backu0 6r`brdAkout 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-pass inspection if(with approval of the Board of Health _ -; .'y ' ) 7 ' broken pipes)`are'replaced ' obstruction is removed °P distribution box is levelled 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 �C a ? 6 • i L revised 9/2/98 Page 2of11 • F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 32 Keel Way, Hyannis, MA Owner: Reba Luker Date of Inspection: June 14, 2000 :.t•i r: +i 1y rt;:�l 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 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) THAT 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. r. 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-to 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 is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 , "SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART A a CERTIFICATION'(continued) Property Address: 32 Keel Way, Hyannis, MA ': . ..,'. , , i , ..t- •.t. ::ss =, ;. •: +., Owner: 'Reba Coker Date of Inspection: June 14, 2000 D. SYSTEM FAILS: You must indicate either"Yes"or"No".as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. 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. ' 4 Yes' No t� . 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 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'i4 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 poo or p rivy 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 I.of a public well:,' • .I�..a. • . y .........�n r.,y..�... t�}•...�.t. ..r .. ..L_�_ .•I: ) IaR• .. .j•y ts.f:w- '•2.I,.L..a i•`,.1.: :4} 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. t 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: t _ 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:, t 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 t 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 Page 4of11 .r t w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Keel Way, Hyannis, MA Owner: Reba Cuker Date of Inspection: June 14, 2000 Check if the following have been done: You must indicate either"Yes" or "No"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. *✓ 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. (*The house was unoccupied.) n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. i ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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: ✓ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. ' revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. d Property Address: 32 Keel Way, Hyannis, MA •+�,.. .'., l _.1`.:. �,• ,.=►c Owner: Reba Coker , Date of Inspection: June 14, 2000 ti ,�� .5 �S•:,::.;. 1 �� FLOW CONDITIONS RESIDENTIAL: Design flow: n/a g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 0 Garbage grinder(yes or no): No Laundry(separate system)(yes or no):No If yes, separate inspection required, { Laundry system inspected(yes or no): Yes T Seasonal use(yes or no): No " Water meter readings, if available(last two year's usage(gpd): Unavailable Sump Pump(yes or no): No �• Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL: Type of establishment: " Design flow: ead(Based on 15.203) Basis of design flow 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) - a Water meter.readings, if available: F' Last date of occupancy: - :'i• �t: t r , _OTHER: (Describe)_ Last date of occupancy: ' � r , {`• GENERAL INFORMATION'. PUMPING RECORDS and source of information: None on file- per treatment plant. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil'al sorption system _ Single cesspool ✓ Overflow cesspool Privy "a Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc. Attach copy of up to dare 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- - - J Sewage odors detected when arriving at the site: (yes or no) No ; revised 9/2/98 Page 6of11 4 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Keel Way, Hyannis, MA •; , ,r� , . .._ a v, . .,£r; Owner: Reba Coker „`, .;;,; ;-y .•,,,; Date of Inspection: June 14, 2000 BUILDING SEWER: _ (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:. None , (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 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.) GREASE TRAP: None (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 Page 7of11 .r SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C x SYSTEM INFORMATION .(continued) j f Property Address: 32 Keel Way, Hyannis, M4 Owner: Reba Luker - Date of Inspection: June 14, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to;or at time, of inspection)' . • i "'A, (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) _.. Dimensions: ;t Capacity: gallons , , R 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 sAztches,etc.) z. t DISTRIBUTION BOX: None ••. r :r • i (locate on site plan) Depth of liquid level above outlet invert: .... ___ .___...__._. __ _ _ t" ,'J' ' • , Comments: a; (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: None (locate on site plan) _Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) I Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Keel Way, Hyannis, MA Owner: Reba Coker v I Date of Inspection: June 14, 2000 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible;excavation not required, location 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: I Alternative system: Name of Technology: Comments: (note condition of soil,.signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) The overflow cesspool was S'W x 6'T x 9'bottom to grade. 71te cesspool was drv. The scum line was 1'up from the bottom. There were no Am of hydraulic failure. CESSPOOLS: ✓ (locate on site plan) Number and configuration: 1 with overflow Depth-top of liquid to inlet invert: -- Depth of solids layer: I' Depth of scum layer: — Dimensions of cesspool: 4'W x 6'T x 8'bottom to grade Materials of construction: Both cesspool block Indication of groundwater: None 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.) The cesspool was dry. PRIVY: None (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 Page 9of11 i I 4 I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION, (continued) . Property Address: 32 Keel Way, Hyannis, ALA i;•. ;;r,s:gib . r,'r !;�.,'? ' •Owner: Reba Coker Date of Inspection: June 14, 2000 Map: 268 Parcel: 209 Lot: 32 SKETCH OF SEWAGE-DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i �ec,`C — — — ,_ A _ 3i 3(p :,t •; •y _ il•aa1t.. r •itt:, -:t. , , 4' .. `t .:54: -,:. _ 1.'a Ct' v-.'. .. `�• .. i:L. Vic..". ..�1 `�•'... , ..i.., •. ., i revised 9/2/98 Page 10ofll ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Keel Way, Hyannis, MA Owner: Reba Cuker Date of Inspection: June 144, 2000 �a NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record f _ Observed Site(Abutting property,observation hole,basement sump etc.). , Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. @Lust be completed) The bottom of the overflow cesspool to grade was 9'. Using the Barnstable topographic map and water contours map, the maps were showing approximately 23' +/-to groundwater. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MI W 29, Zone C, 5/00)was 2.5'. This report has been prepared and the system inspected andpassed as of the date of inspection. Tlus report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11