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T - TOWN OF BARNSTABLE
LOCATION SEWAGE # 63-7
VILLAGE_ I'1 VL"O''►_S ASSESSOR'S MAP & LOT "' !
INSTALLER'S NAME&PHONE NO. ' 50py-4am_1 f n
SEPTIC TANK CAPACITY 0
'try irtes3�X�X.�
LEACHING FACILITY: (type)DA<<°W— S � %0T(size)Cha-,,,vjp!'12.S 3J
I NO. OF BEDROOMS 4
BUILDER OR OWNER t
PERMITDATE: I o� ^o�C' ^OS� COMPLIANCE DATE:
"Separation Distance Between the: '
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. srr P (A-3 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
i on site or within 200 feet of leaching facility) See--o k(0- Feet
Edge of Wetland and Leaching Facility(If any wetlands'exist �w � �
? within 300 feet of Teaching facility) t:(1y1-:eet
Furnished by f
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TOWN OF BARNSTABLE
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VILLAGE ' 0 a S ASSESSOR'S MAP & LOT 2 Z Z —
INSTAL'LER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS (p Y� �� r� �,f n n
BUILDER OR OWNER l 11 i f tit t l��J/V '
PERMITDATE: 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 of leaching facility) '--7'" el", � Feet
Furnished by J
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4
• ,
.V
77 Kelley Road rJ
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is Hyannis MA 02601 03/27/2020
required for every - y
page. City/Town State Zip Code Date of Inspection
.I.r
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. Inspector Information
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
Q Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
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
03- - -20
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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'I of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Please read the bottom of the first page of this report.This statement is from the MA. DEP. This
home was inspected under the MA. DEP and The Town of Barnstable guidelines. This 5 bedroom
home has an H-10 1000 gallon septic tank with a D-Box feeding 2 leaching trenches and a leaching
chamber with stone. The leaching chamber was viewed with a video camera and was appx.1/3 full at
the time of the inspection and no visible failure criteria was found. Note: The system is not rated to
be driven on. System in not in the driveway lay out but one must drive over system to get to the
garage on right side of house. I did a walk through of the home and I found 5 bedrooms based on the
bedroom definition set by the DEP. and the garage is partly finished with a bathroom.
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):
s .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. /" 77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown 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. '
❑ 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): t
4.
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
y i •
.,� 3) Further Evaluation is Required by the Board of Health:
ElConditions exist which require'further evaluation by the Board of Health in order to determine if;t•
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.7126/2.18 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is Hyannis MA 02601 03/27/2020
required for every
page. City(rown 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:
I
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections: r
. I ,
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
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is Hyannis MA 02601 03/27/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or .
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.
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
El El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
4
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C & SAMANTA J SOUZA .
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown 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:
r 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? I
❑ ® Has the system received normal flows in the previous two week period? F
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out? '
® ❑ Were all system components, excluding the SAS, located on site? ,
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue,
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
`t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�V 77 Kelley Road
Property Address
WELLINGTON C& SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 5 + garage is
finished.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
Sump pump? ❑ Yes ® No
5 months ago
Last date of occupancy: Date
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
P ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
Other(describe below):
3. Pumping Records:
Source of information: Per owner pumped appx. 2 weeks ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
•
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18
y ..
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L; 77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is Hyannis MA 02601 03/27/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: µ
® 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
� Depth below grade: 3611feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town water
feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Note there is a sewage ejector pump in the basement. Also information fron the Health Dept. shows
.the garage bathroom ties into the sewer pipe before it enters the septic tank. The bathroom in the
garage was not in working order at the time of the inspection so I could not confirm this.
k
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
I
Commonwealth of Massachusetts
Title 5. 0fficial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
,
Depth below grade: 28"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:
H-10 1000 gallon
Sludge depth: 1 ft of water in tank
Distance from top of sludge to bottom of outlet tee or baffle was pumped
Scum thickness 2 weeks ago
Distance from top of scum to top of outlet tee or baffle per owner
Distance from bottom of scum to bottom of outlet tee or baffle
sludge judge
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.):
recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the tee's were in place and the
discharge cover has a riser installed.
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
77 Kelley Road
Property Address
WELLINGTON C & SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown 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
Distance from top of scum to top cf 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.):
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
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown 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 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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage. The D-Box was opened and there is a riaser installed.
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
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):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 1
❑ leaching galleries number:
® leaching trenches number, length: 2
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ 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
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown 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.):
At the time of the inspection the leaching chamber was appx. 1/3 full and no visible failure criteria was
found. The leaching chamber and trenches were viewed with a camera.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert'
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 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
77 Kelley Road
Property Address
WELLINGTON C & SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
-
page. Cityrrown 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.):
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is H arinis MA 02601 03/27/2020
required for every y
page. Cityrrown 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
1•
l5insp:doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
AsBuilt Paged of I
TOWN OF BARNSTABLE INUI I N ' jV
LOCATION'�`ter SEWAGE q
VILAGE fi B,)40, . ASSESSOR'S MAR&LOT
WSTALLFR`S NAME�PHONE NO: l
SEPTIC TANK:G W.rry
. .}cev ke 9X�X;'
LEACHNC.'FACQdTY;(tya a lltw_ a.I t� )Omiii
N0;OF BEDROOMS y
BUU01ig UR g1WNER
PERMIfDATE:, isO^bS coMpuicE.pAr>
sepunuon Distance Betwun.0 :
MaximumAdiusted:Groundwato.Tablet6i6BotfbmofLeachigFkiliiy _s 063 Feet`
kvite Watt Suppiy.WcH ind:Leaching:FaciHq (If.tiny wells eaig
onlite or wiihip 200 feii of leactung taciliryj p p�fuS_.Feet.
Edge of Wedand and Leach pg Facil 0i.any wetlaad3 exist'
witWn 300'feet of leaching facihry) ` et.
Fuin abed by:
—_— .. ........
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is 1 SIC
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
77 Kelley Road
Property Address
WELLINGTON C &SAMANTA J SOUZA
Owner Owner's Name
information is required for every Hyannis MA 02601 03/27/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
J
15. Site Exam:
® Check Slope
® Surface water
j ® Check cellar
® Shallow wells
Estimated depth to high ground water: 11 plus feet
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:
I augered a hole at a lower elevation to show 4 feet of seperation.
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Kelley Road
•V
Property Address
WELLINGTON C & SAMANTA J SOUZA
Owner Owner's Name
information is Hyannis MA 02601 03/27/2020
required for every
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 '
® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
i
OF'THE,, Town of Barnstable
r
Regulatory Services
r r
+ BARNSfABLE,
MASS. g Richard Scali, Director
1639• �0
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Certified Mail: 7014 1200 0001 0358 1212
June 3,2016 -
Cleia Scatambuli
77 Kelley Road
Hyannis, MA 02601
Finding of Unfitness for Human Habitation and
Determination of .Immediate Danger
In accordance with M.G.L. 6.111, sec. 127A and 127B, 105 CMR 400.000: State
Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR
410.000: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for
Humans. Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable on June 3, 2016 conducted an investigation of a dwelling unit located at
77 Kelley Road, Hyannis, MA. The owner'-s name of this dwelling unit is Cleia
Scatambuli. The occupant(s) name(s) are not know at this time. Based on the
results of that investigation, the Barnstable Health Department finds that the
dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105-CMR
410.831 (D), (E) the Health Department further finds that the conditions within the
dwelling are such that the danger to the life or health of the occupants of the
subject dwelling is so immediate that no delay may be permitted in making this
finding. Conditions found within the dwelling, which give rise to the emergency
finding of unfitness and determination of immediate danger, include:
410. 750: Conditions Deemed to EndanlZer or Impair Health or Safety
410.750 (C)-Electrical service shut off.
Based upon these findings any and all occupants are hereby ordered-to vacate
within(24) twenty-four hours and the landlord/owner is ordered to secure the
subject dwelling within 48 hours of receipt of this order. If any person refuses to
leave a dwelling or portion thereof, which was ordered vacated they may be
forcibly removed by the local Board of Health (Massachusetts General Laws C.
127B), or by local police authorities at request of the Board of Health.
Furthermore, anyone who fails to comply with any order of the board of health may
be subject to fines ranging from $104500. Each day's failure to comply with an
order shall constitute a separate violation.
Q:\Order Letters\Condemnations\77 kelley hyannis _
Once vacated this unit may not be occupied without the written approval of the
Board of Health.
Note: This is an important legal document. It may affect your rights.
PER ORDER OF THE BOARD OF HEALTH
)Wc ean, C � ^ +
Director of Public Health
Town of Barnstable
2
x
4
i�
y
Q:\Orderletters\Condemnations\77 kelley hyannis
Health Master Detail Page 1 of 1
'1th M ster
Logged In As: TOWN\oconnelt Health Master Detail Friday,June 3 2016
Application Center Parcel Lookup Selection Items
Parcel Septic Perc Well I Fuel Tank
Parcel: 292-192 Location: 77 KELLEY ROAD, Hyannis Owner: SCATAMBULI, CLEIA
Business name: Business phone:
Rental property: ❑ Deed restricted: ❑ Number of bedrooms :
Contaminant released: ❑ Fuel storage tank permit: ❑
j Save Parcel Changes I Return to Lookup I
Parcel Info Parcel ID: 292-192 Developer lot:LOT 22A
Location:77 KELLEY ROAD Primary frontage:80
Secondary road: Secondary frontage:
Village:Hyannis Fire district:HYANNIS
Town sewer exists at this address: No Road index:0828
Asbuilt Septic Scan: 292192_1 Interactive map XA<
Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT
Owner Info owner: SCATAMBULI, CLEIA Co-owner:
Streetl:77 KELLEY RD Street2:
City:HYANNIS state:MA zip: 02601 country:
Deed date:10/8/2002 Deed reference:15714/313
Land Info Acres: 0.38 use: Single Fam MDL-01 Zoning:RB Neighborhood: 0104
Topography:Level Road:Paved
Utilities:Septic,Gas,Public Water Location:
Construction Info uildinq N ear Buil Gross ArealLwfng Are bedrooms Bathrooms
1 11950 12844 11483 13 Bedroom 1 Full-1 Half
Buildings value:$106,100.00 Extra features: $22,900,00 Land value: $71,200.00
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=292192 6/3/2016
Citizen Web Request Page 1 of 2
of �nE root �
AV
OA1iI45TAtiLE ^ ♦ew. bIW
MASS,
1639
%Xa.
LoggedAs: Citizen Request Management Thursday,May 262016
TOWN\ocWN\oconnelt
Route to Users Search Reauests Create Requests
Request Information
Request ID: 55616 Created: 3/30/2016 8:43:09 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy `
Health Office
Anonymous: No Request Category: Chapter 170 : Housing
Overcrowding edit
Routine work: No Estimate: No edit
Date scheduled: edit
Estimated 4/13/2016 Change Estimated Mar April 2016 may
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
27 28 29 30 31 1 2
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 A2224 25 26 27
Created By: Wadlington, Ellen Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Request Parcel Map: 1292 - _ _ Block: 1192 A Lot: 1000
This is the identical Number
complaint lodged on June 26,
2013.(1)8-10 cars in yard, Parcel Lookup
front&back,thinks they are
renting out rooms illegally;
(2)Garage was built without
a permit[sending to
Building]; (3)septic installed
without a permit or
inspection. Richard sent to
Building.
" Email:
Edit Requestor Information
Track Request Progress
http://issgl2/intemalwrs/WRequest.aspx?ID=55616 5/26/2016
-
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
i ■ Complete items 1,2,and 3.Also complete A. Sig lure
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse hAz ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Dat f Delivery
■ Attach this card to the back of the mailpiece, 6'
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
�2
1. Article Addressed to: If YES,enter delivery address below: ❑No
1
Cleonice Wadden
.. 77 Kelley Rdad
H annis MA 02601 s. service Type
Y �].Certifled Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(rransfer irurh servicWlabeq ! i7 D 12 i 1 D 1,D D D D D } 2 8 5 D ,i 8 D D 5 l l
Ps Form 3811,February 2004 Domestic Return Receipt 102595M-M-1540 1
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&.Fees PAid
USPS
Permit No.G-10
I •,Sender: Please print your name, address, and ZIP-4 in this box °
I
i
i pTF \ 'I
Tow-n of.Barnstable �l I
Health Division
9 MASS. 1�
,G,9.,\0i' '?_00 Main Street. II
I-Iyapnis,MA 02601'
- I
.H111 .01�
SECTION5ENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY
0 Complete items 1,2,and 3.Also complete A. Slqpature
item 4 if Restricted Delivery is desired. ❑Agent
X
■ Print your,name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. at of Delivery
■ Attach this card to the back of the mailpiece,
or on thevront if space permits.
D. is delivery address different from item if? ❑Yes
.1. Article Addressed to: If YES,enter delivery address below: ❑No
r r =
iL
Cleia Scatambuli
77 Kelley Road s. se oerype
yannis,MA 02601 ,I�/a� Certitied Mail ❑Fxpress Mail
❑Registered ❑Retum Receipt for Merchandise
❑Insured Mail ❑C.O.D.
e
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number ��
(transfer from service/abet)y 11 j 117 012 j 1010 D 0 0 0- 2 8 5 P, 8 012
K
_ !t� _ rat " u �
LPS,Form 38.11,February 2004 Domestic Retum Receipt 102595-024A-1540 1
J
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
•"Sender: Please rent our name, address, and ZIP+4 in this box •
� P Y 'I
' I
Town of*Barnstable +�
5rAoLF- Health Division
16 •m� 200 Main Street `�•
rED MPy° s
{ Hyannis,,MA 02601
• A
�a A
I
I
u J
Certified Mail#7012 1010 0000 2850 8005
��tTOwti Town of Barnstable
. Regulatory Services
BARNSTABM
MASS. Thomas F. Geiler, Director
a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 27, 2013 67
(3
Cleonlce Wadden
77 Kelley Road A,a
Hyannis, MA 02601
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE'SANITARY
CODE1I—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION,
THE STATE ENVIRONMENTAL CODE, TITLE 5.
The property occupied by you located at 77 Kelley Road Hyannis, MA was inspected
on June 27 2013 by Timothy O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of a complaint received at the
Town of Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
410.450 Means of Egress: Observed two rooms within the basement being used as
bedrooms without second means of egress.
You are directed to correct the violations listed above'within twenty four (24) hours
of your receipt of this notice by removing all beds from basement and ceasing and
desisting from using any part of basement as sleeping quarters.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
PER ORDER OF T BOARD OF HEALTH
omas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
QAOrder letters\Housing violations\Rental ordinance\77 Kelley 6-27-13
Certified Mail#7012 1010 0000 2850 8012
`�z Teti Town of Barnstable
o�
Regulatory Services
BARNSTABL&
' Thomas F. Geiler, Director
1639. a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: '508-790-6304
June 27, 2013
Cleia Scatambuli
77 Kelley Road
Hyannis, MA 02601
NOTICE TO ABATE VIOLATIONS OF 105 CMR .410.000, STATE SANITARY
CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION,
THE STATE ENVIRONMENTAL CODE, TITLE 5.
The property owned by you located at 77 Kelley Road Hyannis, MA was inspected
on`June 27 2013 by Timothy O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of a complaint received at the
Town of Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
410.450 Means of Ej4ress: Observed two rooms within the basement being used as
bedrooms without second means of egress.
The following violations of the Town of Barnstable Code were observed:
4 170-4 of the Town of Barnstable Code: Owner's Responsibility to Register Rental
Unit. The unit is not currently registered with the Town of Barnstable Health Division.
You are directed to correct.the violations listed above within twenty four (24) hours
of your receipt of this notice by removing all beds from basement and ceasing and
desisting from using any part of basement as sleeping quarters. You are directed to
register this property with The Town of Barnstable Health Division within fourteen
(14) days of your receipt of this letter.
You may request a hearing before*the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.. '
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
QA0rder letters\Housing violations\Rental ordinance\77 Kelley 6-27-13 11
PER ORDER OF THE BOARD OF HEALTH
YasA. McKean, R.S., O
Director of Public Health
Town of Barnstable
Q:\Order letters\Housing violations\Rental ordinance\77 Kelley 6-27-13 II
Town of Barnstable
Regulatory Services `
Thomas F. Geiler,Director `r
r
BARNS OM
M Public Health Division
1639,iOrEo�° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601 .
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1 Z .24 Df- Sewage Permit# Assessor's Map\Parcel ZI Z /9 Z
Designer: ��U-�• Gl7�•r•-/i�s L�"+, S Installer: IJ
Address: Address: ,() ✓ � / ,v
0 LG If Ir ; I
On was issued a permit to install a
(date) (installer)
septic system at w" based on a design drawn by 1
(address) ` '
(� (�-•�.v.�a�i..�(4i,.,� �•S. dated 1• - l7 per'
r
(designer)
V I certify that the septic system referenced above was installed substantially according to.
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF MgSS90
GLEN tiN
o' �s ERIC a
sta er' Signature) a HARRINGTON c,
No. 1070
• o
s cc-I SSEt���a
C TAF��A r
(Designer's Si ature) (Affix Designers tamp Here)
- A
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE 4 '
= r. RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
1 Y 6
Q:Health/Septic/Designer Certification Form 3-26-04.doc
J
No. C�cd 3 1 - Fee -
'` +`� THE COMMONWEALTH OF MASSACHU SETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfication for ;Migpooat 6pgmem Comaruction 3permit
Application for a Permit to Construct(�epair( )Upgrade( )Abandon( ) El Complete System CLJ 5ividual Components
Location Address or Lot No. re k�r 2 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel yQt.`t�1 r S
-2 19 Z
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �.
7-
Type of Building:
Dwelling No.of Bedrooms _ Lot Size fG/j0-3 sq.ft. Garbage Grinder(/A'd7 �hp�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow O gallons per day. Calculated daily flow -gallons.
Plan Date I Z, 1/7 6T• Number of sheets , Revision Date
Title
Size of Septic Tank r-7c. /000 74/ 1 T Type of S.A.S. S`009A/ C&
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
t✓t� 2 ' 0 it .rAM4 ah f ideli a-1 ✓ e all Gil% I P!nt 14I 4o JiJL�l 07
2 - 3 4 ,L. )c Z ' c✓ X d. S' tom,o /44e/, A^d rs cli e i SI B 2 � 7,04_
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 Certifi-
cate of Compliance has b ssued by ' card of Heal
Si ned . Date _ �® �.
Application Approved by Date �_J
Application Disapproved for the following reasons
Permit No. -Q-.0c 6 Date Issued �d-a.
No:,_:�)ad 5 6 37 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. , -,.•` � Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for-'Migpogar �bpgtem Cons&uction Permit
any
Application for a Permit to Construct(r/)xepair( )Upgrade( );abandon( ) O Complete System LU7ndividual Components
Location Address or Lot No. /�C (�Y i2 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel I` y pl (.1 t'I•t )
Installer's Name,`Address,and Tel.No. rye Designer's Name,Address and Tel.No.
w t :� t fl• S.
s'v Y z 34 z '
'7pe of Building:
—
�,; Dwelling`' No.;of Bedrooms Lot Size . -3 sq.ft. Garbage Grinder(/ja-o7
Other Type of Building No.of Persons Shower's( ., ) Cafeteria( )
,Other Fixtures
Design Flow L� O gallons per day. Calculated daily flow y '-gallons.
Plan Date 17 �i,7�GT Number of sheets / Revision Date ?,
Title
Size of Septic>Tank E/ /000 741 T T. Type of S.A.S. / - SSU 094 l
Description of 12111lo ,
Nature of Repairs or Alterations(Answer when applicable) itd d l�� /- 5 OU 94 / /�/y G h a 11 h e I
0 t f y a,, s: J LLB,e/ (, v,c/J 7`� >l%
L )e 2 L,i X Z. S
Date last inspected: "'✓"�
Agreement: i
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
iri`accordance with`the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate oFCompliance has bem issued by thisBoard of Health.
>. S'gned _ Date j (1
Application Approved b Date
Application Disapproved for hie following reasons :.-�.-: • "`
Permit No. �1. rQ�5 6 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
2g2 -19z-
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded( )
Abandoned( )by 7)t=) , J� vl\ Tf, •Zr 1 —`"
at 7 f e //c Oa*° . �c,/Y "r7�� has been constructed in accordance a
with the provisions of Title 5 and the for Disposal System Construction Permit No.,-) 56- 7 dated ,�I 9 �tr+
Installer ,�.k,e _ ..1�.� Designers I�_;� 1\...i
v ..
The issuance offs permit shall not be construed as a guarantee that the system- i11 inction as designed.
Date 's-' 1 =� Inspector
No.�!`� �. Fee f-�THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ligpogal *pgtem Congtruction Permit
Permission is hereby granted to Construct( pair( )Upgrade( )Abandon( )
System located at �a4i v, i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: ConstructiIon must be completed-within three years of the date of this p i .
Date:__ _. Approved b
1
r Town of Barnstable ' P# 0
Department of Regulatory Services ,
Public Health Division 'Date
`b +ess• .0
�Fn µpl 200 Main Street,Hyannis MA 02601
Date Scheduled o1.1S Time_ Fee Pd. D
Soil Suitability Assessment for Sewage Dis osal
Performed By: (a �E. WA, t i•US 4K R.S• Witnessed By: \ A5 ,
�� *
-Wit. �i�_�.:_�. _ u,�.,jam-S,i� '�__ *_..._T'�s�,rc rw.d,tl7liv,nak.. '_�.:'±3: �1S ,mvz1.s. nas6xl.:^c��e?S,'�.u_• ,i.uL_..y:.�25�wt r.!,haw�� :k _}f .�:C:t LTi
Location Address 7 1`KGl y �� �[Y�i�s Owner's Name S'CAT 444 9(#
Address '77 /( e��•�►?i Q�, Hra� a
Assessor's Map/Parcel: Z ` L 9 a, Engineer's Name G• •• ��� �•S
NEW CONSTRUCTION � REPAIR Telephone# =—
Land Use �'1/4.aCt1XR�kiht�sC Slopes(%) d Z Surface Stones
Distances from: Open Water Body Z� ft Possible Wet Area 9 � ft Drinking Water Well _z!�_#—ft
Drainage Way ft Property Line ` /S ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
s�
• AU, I7
Parent material(geologic) 0*1J 1 u/0-14 l Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: �l� Weeping from Pit Face `M1
Estimated Seasonal High Groundwater ��.�, y • '
. .---._. ._...._ ...__._...__... ..._ _._... .. ... _.......__...,- -
a i e s T lk 7 .;
44 p R `ly' RB �]
4 5.�# hi^A � J �IF'1 2.v'; N�b�S. _ch'v -��..u._�n Y•�
.w+ �r.u ..:.aa_.s�s...x .Sa,E,.,i,..�.s.,r. v :,.�_:r,=_
Method Used:
Depth Observed standing in obs.hole: _ _in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
+ t
i + ,�. x�.ku�,s •arc- utiC nit :�4 "sir-2x.d 'n-
t f ° ,"•'Gr ,w i' r 1131 ai^nr47t
:L�1kt.. xe- imn...'•.1'�xu" i .Mrw.�. .�ti,.�!s�t,!•w-a:.�r
Q,
Observation _
Hole# C Time at 9"
Depth of Perc 3G "SG Time at 6" '
t
Start Pre-soak Time @ �!,G i Time(9"-6") '
End Pre-soak
Rate Min./Inch '
Site Suitability Assessment: Site Passed V } Site Failed: Addktional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back--=----
Q:HEALTH/WP/PERCFORM
4
i
i`y_ fi4 i-?� dss Ye
�SPC,_M 8�'Q �-�. ....._z.'i.'c.:_�.�3'.Si��.'.�rti_..3_._y�'d'a.�!:__ � 5_ s i �'i...��.}�a..,._...
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency,%Gravel
p — � v /F�'�r L S' �oA& 3/2 ti
(0-32, 13w
32-0Z C f wr-c SaMd 2_ SY7/-3 ,vo VC, Y- ew,
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/Va vas �•-w
i 4/
k.r4��iYc...d"�i3ei'd-.,.'fiz."c.x.',f 3. 'Er'i'S.�.u�,9w x.b. i5.---•iw.]cY _7�h_.__;..:.�. i ?`_...._w.}ti��,._.�,_ ._ •__:�r,�f '5..F._:T �_:s
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(iii.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency,%Gravel
� -�� ?fit... � S is 'rQ}�� �° •
7 /o t;r�1 „
7 r-M C /I --COS Sa4ld_ 2�S y NU var wdi e- 14
0I's 0-a
''v h,�i._' s a. iT .t'r'�v;� .y /'�•'�4� ry',y?. "+ ]^' r6 nsw M a }.ter pry{. -iW P i un
Mw�w i i' ,.rr tPiV �3'1,icy'L` Ul'\.`rl. Jl:%fJ'JS�.Y'_`h'aT ta{>4 `4V1.r,4ntf. iz v.wls I RF
Mn_i .�I_.•z.u�gix+l4ilu.ffL+l C,�_ uu•_'�_._if. ..nui_S.:S+IL..,+..L�d�..1uTA.4. .!•s r __•.c_._�.C__ L,J�
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
[,Consistencv.%Gravel
a as ,4 r 7 R .�j ��_ a m4 :i y.F
y�#� 25:� sr fir+ - jl]J;C+ � 1 �+ 1y.1 � Jr�`. t � 0. stQ��hTT d`•. k�f�,s.. k
?vim r..w..I;.....u.i}3�.w 9��25.Y4'�iP:1�7S..,aa::ih=,ssY?�ct,,d1Y3 }f&�n.S:'.:�Fr1.,�9�n 155�i�Ttli.�c.4� S,tnsti.d td.e
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistenc %Gravel
• I
i
yy
Flood Insurance Rate 1Vlajr•�
Above 500 year flood boundary No_ Yes -�"� ��' lr''. �+. � �'`'"'`•r
7
Within 500 year boundary No_ Yes
Within 100 year flood boundary,No_ Yes
(C^ r,G<ty 1"• .A ry^i,�t,• ;,.J•�!; •rt(fit•
Depth of Naturally Occuriing Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? �
If not,what is the depth of naturally occurring pervious material?
Certification \ti)`:
I certify that on (0 (date)I have passed the soil evaluator examination apprld by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
Signature_ Date�1710
Q:HEA,LTH/WP/PERCFORM
t .
t
r
iu Ti
Pd ler
S��r go.5
DATE 5/3/05
Road
PROPERTY ADDRESS 77 KeiPey
Nas.a �02601
On the above date, th"Optic system at the address above was
inspected.
This system consists of the following:.
1., 1-1500 gaiion eept.ic tank.:
2., 1- Di sta igut.ion Box,,.
3., 2- -34' Leach.ing taenchez 34'LX2%b1X2' [7
c
—c r
Based.on.inspection, I certify the folloi�ting conditions: n
4., ' 7h.is is a 7.it.2e Five Se/2t.ie zystem.l
CIO
5:, Septic .6ybt' m .is wo2k.ing p2ol2e2.ey., 11oweve2 the2e 4- �
a apaziment 'above gaaage :that .is connected to zept 'c w co
ayztem.. 7h.ih zyztem 1.3 oney ae'zigned boa 3 beds., t m
above gaaage would make a Boaad O, . .e h .2i
make deteam-intat.ion., SIGNATURE
Name: Robert A. Paollni :.
Company: Joseph P. Macomber &Son Inc .
Address: P. 0. Box 66
Centerville, Mass 02632
Phone: 508 775.3338 or 50&775-6412
jDSEPM P. MACOMBER & SONt. INC�
Tanks-Cesspools-Leachfields
•Pumped &.•"Installed
Town Sewer-Connections
P.O. Box 66 . Centerville, MA 02632-0066
-778,3336 . 7.75.64i2-
COMMONWEAL' OF J1W-SACHUSETTS AIDS
E+XECUTWE•.OMOE OF EI R®NM'EN'TAI.AFF
DEPARTMENT OF ,QT�21?iEN'1`A3�pR0`1CTION
r :
TITLE 5
OFFICIAL INSPECTION FORM-NQE�I0RV0L NT-AR M FORM MEW
SMURFACE SEWAGE ..
FART•A
CERTIFICATION- r
Property Address: • 7 7 K r'�-
ann�is (�a �, Z
Ro e2to Sca.tam&u—P� r --C c
owe ees Name: _ -,I
Owner's Address: u n n o wn (/) co r
Date of Inspection: 41271
Nance of Inspector:Iplease print,,
Mn
Company Name: � _
Mailing•Address:
�n iav c e 1 ,6b.•02¢32 .
Telephone Number:
CERTIFICATION STATEMENT .
1 certify that I have personally inspected the sewage disposal,system,at this address and that'the.informatlon reported
fY inspection,'>;lte inspection was performed based on my
below is true;accurate and complete as of the time of the insp
ce of on.
training and experience in the proper ftit eden and mime onan Tit 5 E31 sewage�5:•8disposal
0j a The system-
approved a DEP
approved system inspector pursuant to•SBetion
Passes
-Conditionally Passes roving Authority
XXXXNeeds Further Evaluationby the Local App
F1
--� Date. � S
InspEctor's Si�nat�are:
ectinn ieportto the.Appr0An$Atdtwrity•(Board of Health or
The system inspector shall submit a copy of this�P or has a design flow of 10,000
DEP)within. days of completing this inspection.If the systeiti is d.Awed•sY onsl ofE�of the
ector and the system owiter.s�iall submit the report to the appropriate'regl
gpd or greater, the insp acabie,and the approving
DEP.The origmal should be sent to-the system v`xncT=&copios scntto the buyer,if�Q4
authority. :
Notes and Comments
f use Bt-that
**** only describes conditions at the time of inspectidYt'and uncle then a rime sa^aome or different
'l�hts report Y
^ time.This inspection does not address how the system will perform in thefuture
conditions of use.
• _.__v�.... naoP 1 •
Page 2 of 11
OFFICIAL INSPECTION:FORM—NOT,FOR VOLUNTARY ASSESSNMNTS
SUBSURFACE SEWAGE DISPOSAL SYSTZM INSPECTION FORS.
PART-A
CERTIFICATION(continued)
Property Address: 77 k e 2.2 Road
yanniz
Owner✓2oketto Sca.tagaPi
Date of.Inspection: 4/2 7/0 5
Inspection•Saminary: C6iIc�C A;#i;C;D or.E/AI `complote:all of Section D
A. SystemPasses:' Need.a �u2the z eva..euat ton &y. liea2.th [fie/2.t
I have not found any information which indibatest of any of the failure criteria described in 310 CMR
15.303.or in 310 ChM 15.304 exist.Any failure criteria not evaluated are indicated below:
Comments:
B. System Conditionally Passes:
NO One or more system components.as described in the"Conditional Pass"'section need to be replaced•or.
repaired.The system,upon completion of-the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"ndt determined"please
explain.
'NO The septic tank is.me%l:and.over�0 years old*or the septic-tank.(w..hether.metal.or not).is:slJracturally
unsound,exhibits substaatiallinfiltration or exfiltration.or-tank-failu v1s linen;:System.will pass ulspection.if3he
existing tank is replaced with'a complying septic tan k.as-Apprsved by.the':Soard of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certifioate of Compliance
indicating that the tank is less than 20 years old is.available. '
ND explain:
NO 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 broker,settled-or uneven distribution box.System will pass inspgction.if(with
approval of Board of Health):
broken.pipe(s).are replaced. .
obAmdt on is removed* - r
distribution box is Uve.W br:'eplaced
ND explain:
NO The system required pumping:.more than 4 tunes a year due to broken or obstructed pipe(s),The system will
pass inspection if(with approval of the'Board of Health): ►,.
broken pipc(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OVY;•CIAL MFECTION FORM•NOT VOR VOLUNTARY ASSESSMENTS
SUBgtWACE SEWAGE DISPOSAL' SYSTEM INSMCTION.FORM
PART A.. .
'CERTIRCATION'(4mitinued)
Property Address:7 7 K e i i e tl T?o a.d
K ann.i
Ownen.Ro.&eato ca am ui i
Date of Inspection: 4/21/0 5e
C. Further Evaluation-is.Required by the Board of Health:
Conditions.exist whicliaequire further..aualuativn.by.the.Board:of�•Health in•ordento;detertnine ifthesystem.•
is failing to protect public,health,.safety or the environment.
1. System will Pass unless Board-of Healtb deteratinesdii ataordance with 310.CMR 15:303.(1)(b)that the
system ismot functioning in.a•manner:which*01 protect public health,safety•atr¢.tbe..enxiroament:
n o Cesspool or privy is within-50 feet of asurface water
n o Cesspool or privy is within 50.feet of-a bordering vegetated wetland or a salt marsh.
2. System will fail unless the Board•oi Health(and Public Water Supplier,-if any),determines:that the
system is functioning in a niatiner.that protects the public Health,safety and environment:
no The system has a septic tahk and soil'absotption'system(SA-S).:and the SAS is within 100 feetofa
surface.Water supply ontributary to a surface water supply.
no The system•has•a•septie tank and SAS and the:SAS isvithin a Zone 1 of a-public water�supply.
no The system has aseptic tank and.SAS:and-the SAS Is within,50 feet of a private water.supply well.
no The system has aseptic tank and SAS and.the-SAS is less than 100 feet..but 50 feet or.1hore 6onla
private water supply well".Method used to determine distance-V:i.�ud�
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic conipounds indicates that the WelUs.free from•pollutioti from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or.Jess than 5.ppm,.provided that no-other
failure'criteria are triggered.'A copy of the analysis must be;attached to-this form.
3, Other:
Gaaage haz a apaatment with. I &edzo-om.- No.t'Ung z.6 on &ie.-
7heae .i.s a 3" 2.ine go ing ,01Lom apaatment .into zP,124.ec ,boa ho e.-
Page 4 of 11
OFFICL L•INSIPECTION FORM-NOT TOR,YOLUNTARY ASSESSMENTS
;SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSFECTION.F.ORM
PART A
CERTMCATION, (continued)
Property Address: 77 ke.eeeq Road
yaniz cis
Owner: Ro&e/zto S*catamguii
Date of Inspection: 1
D. System Failure Criteria applicable to all systems:.
You must.indicate."yes"-or"no"to each ofthe:following,for all-Inspections:
Yes No
_ . X Backup.of sewago:into�fadlity.:or system component due_�to overloaded:oi clogged SAS..:nr.cesspool
.X '.Discharge:orponding of effluent to the,surface of the.-Opund Qr..surface:waters due to an•overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool '
X Liquid depth.in-cesspool is less thank"below invert or availablo volume is less than'%-day flow
X Required pumping more-than times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below High ground water elevation.
Atiy.porrion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface
T water supply.
_ X Any portion,ofa cesspool-or privy fswithin a.Zone! ,ofa-public.well..
X 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 54 feet from a.private.water
supply well with no acceptable water quality analysis..[This.system.passes if the well wateranalysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds
indicates:that the well is.free from pollutio0romAltat1acility 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-niust be attache&to this form.]
N•0 •(Yes/No)The system falls.I have determined that one ormore,of:the:above.failure.criteria exist as
described in 310 CMR 15.303,therefore the.system-..fails.The system owner.should contact th8 Board of
Health-to determine what will be-necessary to correct the failure.
E. Large Systems:
To be considered a large system.the:systtm must.serve.a!'aeility,with a.design flowof 1,0;00.0 gpd to 15i000.
gpd, •
You must indicate either"yes"or"no"to.each of the following:
CMe following criteria apply to large systems in addition to-the criteria above)
yes no
X the-system is within 400 feet of a surface drinking water supply
X the system.is within 206 feet of a tributary,to a surface drinking water supply
X. the:system is located In a nitrogen sensitive area(1nterim Wellhead Protection Area IWPA)or a mapped
Zone 1I 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 tinder 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.
4
G
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
r— SttSURFACE-SEWAGE DISPOSAL: YSTEM INSPECTION FORM
PART B
CHECKLIST
7 7 K e U e y ./2 o a d
Property Address:
yann.tz
Owner: /20 gea.t o •i
ca am u
Date of Inspection: 4/27 0 5
Check if the following have been done You must indicate,yes or"no"a..to each of the following:
Yes No _ .
— _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of thisinspection?
X _:Were as built plans of he systom,obtained and examined?(If they were not available tote as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site'inspected for signs of break out?
X • _ Were all system components�,�luding the SAS,located on site.?
X 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?
X _ Was the facility owner(and occupants if diffdrent 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 deternwted based on:
Yes no
— x Existing information:For example,a plan at the Board of.Heal& "
_ X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
CMR 15.302(3)(b)]
is unacceptable)[310
Page 6 of 1 I
OFMAL IgSPF,CTj0N 1F- RM—N0T FOR VO.LI NT:ARY ASSESSM EN T
SURSU.RFACE-S V.AOE D1$P.;OSAL{SYST9rWJNSPEETION:FORM �
PART-C
SYSTEM.INFORMATION
Property Address• 77 Ke�.�.2eu Road. Nu anniz
Owner: Rogezto catam-gui .
Date of Inspection:- 5
FLOW CONDITIONS
RESIDENTIAL 3 t�. a s a e a t 1 g e cl
Number of bedrooms(desjgq):-Y Number of.bedrooms.( etual): . , . y - /� .
DESIG9.flow based'on*3'10 CIM 15.2.05':(for exai iple:*1 I0'gpd x#-ol'bedrooiiisy 1 /0=3 3 0 G P D
Number of current residents- ..
Does4esidence have a garbage grinder(yes or no)n o
Is laundry on a separate sewage.system.(yes or.no):.rz oo [if yes separate insiaeetion required]
Laundry system inspected(yes or no): ri o
Seasonal use?(yes orno): .rz0 2003=87, 0.00ga eion.3 GP D=238., 36
Watei meter readings,if available(last 2 years usage(gpd)):2 0.0 4=12 6, 0 0 0 g a e e o n,3 G P D. 3 4 5 21
Sump pum (yes or no): n o
Last date o�occupancy: /2 2 e z e n t
COMMERCIXIUSTRIAL
Type of estabi f ..s� t N;4
Design flQw. KIN
on310 CMR 15.203):. �pd
Basis.of dUigirirflow(seats/persons/sgft,etc J:
Grease trap,#esent(yes or no):
Industrial waste holding tank present.(yes or no):_
Non-sanitary waste discharged to the Title 5 system.(yes or no):
Water.meterreadings,if available:
Last-'date of occupancy/use: .
OT) R(desgnbe):.
GENERAL INFQRMATION
Pumpicords
Source gReormat am ed tank 3130104 ,z maint ^
Source of information: � � � .
Was system pumped as part of the inspection(yes or no):rjQ.
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for-pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption.system
_Single cesspool
—Overflow cesspool
_ivy
_Shared system.(yes or no)(if yes,attach previous inspection retards,if ahy)
_Innovative/Altemativetechnology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a.copy.of the DEP.approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
4.n4taiied 6-/11198 &u J / Ploa iz
Were sewage odors detected when arriving at the site(yes or no): n o
6 -
Page 7 of 11 .
OFFICIAL� INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(continued)
Property Address:_ 77 Ke eiey Road
flc/ann.�.s
Owner: Roten_to acatamgu.e.i
Date of Inspection: 4127105
BUILDING SEWER(locate on site plan)
Depth below grade:Z 0"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance fiom private water supply well or suction line: 10 t Ze e t
Comments(on condition of joints,venting,evidence of leakage,etc.):
ghin
onts a
h0u,3e vent..
SEPTIC TANK:y f-Alocate on site plan) 1500 ya e e o n
Depth below grade:3 0"
Material.of construction:X concrete metal fiberglass_polyethylene
other(explain) — . — —
If tank is-metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: 10' 6'LX5 ' 8019X5 ' 70K
Sludge depth: .tea ce
Distance from top of sludge to bottom of outlet tee or baffle: t/z a c e
Scum thickness: it/zace-
Distance fiom t0i of scum to top of outlet tee or baffle: t 2 a c e
Distance from bottom of scum to bottom of outlet tee or baffle:--t�e
How were dimensions determined; m &,,,Q
Comments(on pumping recommendations,inlet and outlet tee or baffle conditio structural
as related to outlet invert,evidence of leakage,etc.): integrity,grity,liquid levels
Pu,mp tank oi). Dyeaz6.,
Tank j.6 .3t2ucta
GREASE TRAP:N 0(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(on pumping recommendations,inlet.and outlet tee or baffle condition,structural
as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels
TMA i Tnenn�finn Fnrm An ev,)nnn 71
Page 8 of
OPTICIAE INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
S .RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C•
SYSTEM INFORMATION(continued)
Property Address:77 Ke$eeu Rpad
17'u 3
Owner,Roge2.to
Date of Inspection; 4/ z I/-u
TIGHT or HO•I,DING TANK: NO (tank must be pumped at time of inspection)(locate on site plan)
Depth be+ow,grade: .
Material of construction: Tconcrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity:' .gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working.order(yes or no):
Date of last pumping:
Comments(condition of alarm and float-switches,etc,):
DISTRIBUTION BOX: Ye-3(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.):.
Box' .ih .$eve2 ,No zo.Q.id ea2�zu ovea.- Box ha.6 3 ea.te2ae,6.1 No 6incq,3
—;& $eakage .in oa,xu# oP lox.,
PUMP CHAMBER: _ly_Q(iocate on sife.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,etp,):
Pump ehamge2 .ih no.t• /22ezenl.,
8
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
--~. SUBSURFACE SEWAGE.DISPOSAL SYSTEM INNSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 77 1Ceeeeti Road
uann.is
Owner:.Roge2to Sca.tamtluti
Date of Inspection: 4/2 7/D 5
A.
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located see i2a" I
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:2-3 4'LX 2 z 'W X 2' !D
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Com
ments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,
etc.):
Loamy to
So.i.2.6 ate dz
CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
C.ezis ooiz ate not
PRIVY: NO (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.):
2-iv .i,3 not a
9
i
e
Page 10 of 11 -
- SPE TION-.VOR�Vi�NOT*Foi;t•?VOL-UNTARY:ASSESSIVIENTS -,
0m.CL&.L IN SE ACHE lgP.OSAL-•SySTEI*.INSPECT -ION- U1
SUB- PAR' C
SYS'• .EM WFO C'TION(icontinned)`
Property(Address: 7
jZyu¢nai
Ownei: l20 ea
o ca amplu i c
Date of Inspection: /2 7/0-5"
SKITCH OF SE'WAGF,•DISPOSA,L SYSTEM ties to at least two perinanettt reference lsn or
Providers sketch of the sewage disposal system including ublic�vter.supply enters.the building.
Provibencde
.. locate all wells within 100 feet.Locate where p
14
OPT
10
Page 11 of 11
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY C FORM ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INS
PART C
SYSTEM INFORMATION(continued)
Property Address: 77 Keeeey Road
yanR.is
Owner-.R09e2to Scatam9uti
Date oflaspection: 4127105
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells.
Estimated depth to ground water 5 0 feet ,
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
u e.s Observed site(abutting property/observation hole within 150,feet of SAS)
Checked with local Board of Health-explaima.4 9.u i t r n n
no Checked4ith local excavators,installers-(attach documentation)
e.6 Accessed USGS database=explain.
R� own.��a2n� a&fie. ma. us
�--.. You must describe how you'established the high ground water elevation:
Uzed : Cape Cod Comm.iz.ion 1date2 7aa-ee Coritou2h ,4nd Pug-eic IVate2
Ue$2 head aotect.io�n a/teas ma Se t 1995
Glatea 2e-6ou2ce3 o .ice cape co comm.izion.,
Leaching
7anc es'e . 4 Beet
Groundwater:4 6 Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is.4.,8
'feet.. 4 9 2
11
TR!AC•T�\RnT"!:ice-.T-•
At
7•�nnr•u rn•,sr••a•rsrr•am:non►rs-nnesrtrerarnm-►+,tw►��*sent�rm�rratssn •}
'TOWN OF BARNS7RBLt BOARD OF 11EALT11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D•- CERTIFICATION
«. -r•:-:: - +ssr.^.rrnrnrm•n,r�rv+rn.r"Irl.111 .:rxnr.svr+r.•��mtn—•1'�+ �"^�0'^QR .
—TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED ,
STREET ADDRESS 77 Ke.Uey Road Hyanaiz Maz.6
ASSESSORS MAP, DLWK AND PARCEL # 2921192
OWNER's NAME
Rogezto .6ca.tam&a_U
PART` D - CERTIFICATION
NAME OF INSPECTOR Roge.¢�E !a.o•i:ini
COMPANY NAME
o.5e .h % Nacomlel?l Son Inca /�
Box 6 6 Cen�e2vi-Ue l a s,s- 02632
COMPANY ADDRESS Town or City. Stag LIP
street
COMPANY TELEPHONE ( 508 ) 77.5 - 3338 .FAX ( 5.08)790 - 1578
CER,rI-FICATION STATEMENT
I certify that. I have personally .inspected ..the sewage disposal system at
this Address and that the information reported .is true ,. a.cetir.ate, and
omplete as of the time .o:-f .insp.ection.• The inspeeti.o:n was performed and any
recommendations regarding upgrade , maintenance , and repair .are .consistent
with my trainit, g and experience in the proper function and maintenance of on-
site sewage disposal systems -
.
Check one: B ' `
System PASSED
&d#M"4 Ou"
The inspection which I have .conducted has .,not found :any information .
which indicates that the system .fails to adequately protect .public
health or the environment as defined in 310 CMR. 15,303, Any failure
criteria--Dot evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con 'ted has found that the system fails to
Protect the public liealth and the environment in accordance with. Title
51 310 CMR 15 . 3031 and as specifically noted on PART C - FAILURE
CRITERIA of this inspection .form.
Inspector Signature ' v Date
One copy of this ce'rti f icat o' -n must -lie provided 'to the OWNER, the. BUYER
where appl i.aable) and t.h?e BOARD OF HEALTH, .
* If the inspection FAILED., th*v owne.r• .or operator shall, upgr.ade.' the system.
within obe year of the date of the inspection, unles.s. allowed or requAred
otherwise as provided in 340 CMR 15 , 305 ,
�.. Dar.td.d ony
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
•u
e
i� SVev
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RECEIVED
PART A
CERTIFICATION JUL 2 5 2002
Property Address: 77 KELLEY+RD HYANNIS, MA 02601 29 21 q Z �0 TOWN OF BARNSTABLE
Owner's Name: MR. CUNNINGHAM HEALTH DEPT.
Owner's Address: 77 KELLEY RD HYANNIS, MA 02601
Date of Inspection: 7/3/02
Name of Inspector: (please print) , 1 JOHN GRACI
Company Name: SE PTIC INSPECTIONS lam/
Mailing Address: P.O. -OX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813 FAX 508 2564-7270
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address .nd 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
—e�fence in the proper function and mair_ten*i1ce of on site sewage disposal systems. 1 am a DEP approved system
inspectar�pursuant to Section 15.340,of Title 5(310 CMR 15.000). The system:
X PaInae,
_ CosesNealuation by the Local Approving Authority
FaInspector's Signature: Date: 7/3/02
The system inspector shall suf this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this ine system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shafl'submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent tc the buyer, if applicable,and the approving authority.
f:. N
r•.l: a. •.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERT'TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND RAISING ALL COVERS.
****This report only describes`conditien:;at the time of inspection and under the conditions of use ul that time.This
inspection does not address how the:system will perform in the future under tl.c same or different conditions of use.
j
Cla
Page 2 of 1 I
•
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property Address: 77 KELLEY RD HrYANNIS, MA 02601
Owner: MR. CUNNINGHAMI iL:
Date of Inspection: 7/3/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any infornlation lwhicli indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria`hot evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND RAISING ALL COVERS.
B. System Conditionally Passes:
_ One or more system components-as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,.as approved by the Board of Health,will pass.
Answer yes,no or not determined�(Y,N,ND)'in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 2W ears old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltrAiibn ortank 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 yearN•Id is available.
ND explain: n/a
n/a Observation of sewage backup or break.ouf or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health): ,
_ broken,pipe(s)_are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 'file system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board`of Health):
_broken pipe(s)are replaced
_obstruction is removed
R;
ND explain: n/a
.':PIS. ...
7
t
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 77 KELLEY RD HYANN;IS, MA 02601
Owner: MR.CUNNINGHAM
Date of Inspection: 7/3/02
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..
. o
1. System will pass unless`Boardof Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner wliich will protect public health,safety and the environment:
Cesspool or privy is within 50',feet of,a surface water
_ Cesspool or privy is witk ,50 feet of a,bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning.in a,manner that protects the public health,safety and environment:
SN
The system has a septic tarik'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 andSAS and the SAS is within a Zone I 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 deter ine distance n/a
**This system passes if the well wat'er'arialysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compou118S indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is.equal•to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to-this form.
3. Other:
n/a ;13tr1 .
tlla�a;ti. '
Page 4 of I I
a
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 77 KELLEY,RD HYANNIS, MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
D. System Failure Criteria.applicable.to.all systems:
You must indicate"yes"or"no to.,eaeh of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters,due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the disiribu:ion box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than`6"below invert or available volume is less than %day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped PIIMPED TWO YEARS AGO BY OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy.is within a Zone I of a public well.
X Any portion of a cesspool or privy,is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP
certified laboratory; for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution fromathat'facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form:It _
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the sysiei>'i`fa�lsi The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems: �4r1
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large sylstems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet off a tributary to a surface drinking water supply
.ij ,73;.F'.3
_ X the system is located in a nitrogen.sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public'water supply well
If you have answered Vyes"to any.question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large syslein 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 re1gi,1onal,of ice of the Department.
Ali.l ie'
Rage 5 of I I
OFFICIAL INSPECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACC.`S.-EWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 77 KELLEY RD'HYANNIS, MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
Check if the following have been done. You must indicate "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 Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period '?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling,inspected for signs of sewage back up`?
X _ Was the site inspected for signs of break out'?
X _ Were all system componeri(s;excluding the SAS, located on site'?
X _ Were the septic tank r'riariholes'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'?
X _ Was the facility owner(and occupants.if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
r,
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CM 15.302`(3)(b)]`
•i v, .•,
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Page 6 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE°SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 77 KELLEY RD HYANNIS,MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3',.,Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR`15.203 (for`example: 110 gpd x#of bedrooms):330
Number of current residents: 2
Does residence have a garbage grinder(yes;or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(Iasi 2 years usage(gpd)): Ww - —131DD0
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMM ERCIAL/INDUSTRIAL'' '� '
Type of establishment: n/a "''( T I
Design flow(based on 310 CM I' ;2,03): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO ,,,
Industrial waste holding tank present(yes.or no): NO
Non-sanitary waste discharged to tile lTitlle 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
'GENERAL INFORMATION
Pumping Records
Source of information: PUMPED TWO YEARS AGO BY OWNER
Was system pumped as part of the inspection:(.yes or no): NO
If yes,volume pumped: n/agall'ons-- Flow was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,so�il;absorpfion"system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes;Eattach previous inspection records, if any)
_Innovative/Alternative technology,.,Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the'DEP approval
Other(describe): n/a
Approximate age of all components„date;nstalled(if known)and source of information:
r!
1952 BY OWN R,NEWER SYSTEI-M:1 YRS 01,1)
Were sewage odors detected when arriving at the site(yes or no): NO
�r
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cont'nued)
Property Address: 77 KELLEY RD HYANNIS, MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
BUILDING SEWER(locate on:site plan)
Depth below grade:30"
Materials of construction:_cast iron':'X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,,evidence.of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 24"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain;n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6" W
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
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 were dimensions determined: MEASURED
Comments(on pumping recommendations, i%let and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPOINENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING'EVEftY TWO.-YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site-plan .
Depth below grade: n/a
Material of construction:_concrete—metal'—fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
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
Date of last pumping: n/a
Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,et .):-.,,
n/a
i
'Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 77 KELLEY RD HYANNIS, MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/AF,
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X must be opened)(locate on site plan)
Depth of liquid level above outlet;invertn LEVEL WITH BOTTOM OF PIPE
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 WAS VIDEO INSPECTED'AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site.,plan): I,
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
tip
i
r
. Q
I t,:
Page 9 of 11 4?
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 KELLEY RD HYANNIS,MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02
SOIL ABSORPTION SYSTEM (SAS): A (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
I
Type
n/a leaching pits, number: n/a
n/a ieaching chambers, number: n/a
n/a leaching galleries, number: n/a
2 leaching trenches,number, length: 34
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a 't. ; innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs�of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
TRENCHES ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert:'.n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
T .,..
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.; PART C
.SYSTEM INFORMATION (continues,)
Property Address: 77 KELLEY ItD.H.YAVNIS, MA 02601
Owner: MR. CUNNINGHAM
Date of Inspection: 7/3/02.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal 'system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
C
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4Jj
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 77 KELLE`Y RD HYANNIS, MA 02601
Owner: MR.CUNNINGHAM
Date of Inspection: 7/3/02
9 '
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water'12.+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavafor's, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the,high ground water elevation:
HAND AUGER- 12+ FT.
Ip.t tih.
l
II
G
TOWN OF BARNSTABLE
LOCAT19N _ SEWAGE # Z a �
VILLAGE_ ASSESSOR'S MAP & LOT 3A - i 74-_
INSTALLER'S NANd&PHONE NO.
SEPTIC TANK CAPACITY �� - if
LEACHING FACILITY: (type) (size) o`Z'
NO.OF BEDROOMS
BUILDER OR OWNER r
PERMITDATE: to ~ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility °� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 290 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
1. within 300 feet of leaching facility) Feet
Furnished by
z X�� X h� � �• .�,.
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Yr J
L
rya a• �. ��+�.-. Y E ,:
No. — �� Fee �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2ppficatton for Mtgoal *pgtem Comaructton Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location'A7 ss of �oy` Owner's Na Address 1.N o.„ `
Assessor's Map, lel i� `
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
aZ-3 O
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -3 3 y gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /5 i_2 o Type of S.A.S.
Description of Soil
�— vU Nature of R pairs or Alterations(Answer when ap licable) �
:Z.L S0
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 Titl 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by t is Bpo of4alth.
Signed Date
Application Approved by Date (
Application Disapproved for t e follo ' g reasons
Permit No. G l Date Issued
TOWN OF BARNSTABLE
.:;LOCATION _ SEWAGE # r F—3CI1
LAGE ASSESSOR'S MAP& LOT
-INSTALLER'S N &PHONE NO.
. .......... .
SEPTIC TANK CAPACITY lS— �.
LEACHING FACILITY: (type) cay (size) 02" 3 7 se 1L�
NO.`OF BEDROOMS 3
:BUILDER OR OWNER 'F
PERNIITDATE:� (e — 1 —'� COMPLIANCE DATE:_ —// •9
;Separation Distance Between the:
IvlaWum Adjusted Groundwater Table and Bottom of Leaching Facility ; Feet
:Pri'vate'Water Supply Well and Leaching Facility (If any wells exist
;on,site or within 290 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
;: within 300 feet of leaching facility) I Feet
F mshed by
R ...
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G. J L6
rx (3
c
i� -..-. 7'"��... 'f�'_`Yrw",1,-7'r.`�".FIa7"'�-!'w`.ti•aY''x,�•r'v.-_:....•.y!'+.Ya-7rv�;�rsww'r'y^'"'.+".va w+�--..r.i,s..+.-..r.F++rwY+..rx.Hr+:.-�v-,+.i�eiw..wyFai+-...i:.,+:a..r�h+i""�Y'++t'r'"rr..�rt
No. r., - '
_ Fee
THE fOMMONWEALTH OF MASSACHUSETTS Entered incomputer: -
PUBLIC HE TH'I�t lr0iV — TOWN OF BARNSTABLE., MASSACHUSETTS Yes
• 4 s
Application for Xh5*ar �bpgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Qddre ss t Ows Na Address ael.NN�iI.��C
Assessor's Map/Parcel
4 _
1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Q e::�3o
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic-Tank /574.>o Type of S.A.S. 7
Description of Soil
i
Nature of R pairs or Alterations(Answer when ap licable)
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#,.•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 provisionQeerTitti 5 of the Environmental Code and not to place the system inoperation until a Certifi-cate of Compliance has been issis B of lth.
c
4, Signed Date 4; 17'1 �?
Aoplication Approved by Date
Application Disapproved for theelfollov4g reasons +
1
Permit No. 1'�< G / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of QCompliance '
THIS IS TO CERTIF tha the On-site Sewage Disposal System Constructed( )Repaired ( Y) Upgraded( )
Abandoned( )by ._
at 7 G has been constructed in accordance
with the provisions of itle 5 and Ike for Disposal Sy tem Construction Permit No. / '3 G/ dated_ G —!!— S
Installer Designer
The issuance of this permjt shalt t be�0 trued as a guarantee that the system will fun�ction as designed.
Date , Inspector (� _ io__,�
No.
--------Fee----
— (��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
&pgtem Conotructiou Permit
Permission is hereby granted to&onstruc )Repair( Upgrade )AbandQn( )
System located at 77
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions., i
Provided: Construction must be completed within three years of the date of this permit.
Date: fig -// -0/�j Approved by
i P 1
10/9/97
I
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND.APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the applica ' n for disposal works
construction permit signed by me dated cerning the
property located atAemeets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
✓ • There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will n2i be located less than fourteen(14)feet above the maximum adjusted -
groundwater table elevation.
Please complete the following: °
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well mapp�_
SIGNED : DATE: f�
LICENSED SEPT YSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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31, 811
HALL
.' 9' 3" 3' 7 3 1/2
BATHROOM KITCHEN
.CLOSET co
- 41 .70 s ft
�> q 54.67 sq ft'(5' 7 3/4" x 9' 8")
5'i 8 3/4" x 7' 3 1/4"
. _ in a
BEDROOM
v 97.85 sq ft (10' 7" x 9' 3") ol Of
(v
D HALL
a) ,
ky
165.45 s ft (15' 6 1/4" x 10' 8") 1
LIVING ROOM N
BEDROOM 136.95 sq ft
` °° 98.64 sq.ft (10'. 8" x 91 3") 9. 8" x 15' 6 1/2"
I
20' 9"1 �_ 3' 8" i 5' 711
.. r?
4,
J tY
U3
HALL
Y y 529.61 sq -ft (31 ' 9 1 /2" x 30')
N
9EM ROOM N
133.89 sq It
9' 8" x 15' 6 1 /2"
9' $,1
11' 4"
a'
' •cn PLAYROOM
.197.79 sq ft (17' 5 1/2" x 11' 4") •t
6' 6 3/4" 11' 4 1/2"_
,.BATHROOM Q tif�
50.85 sq ft . LOSE
• 7' 9" x 6' 6 3/4" B r
W KITCHEN BEDROOM
144.68 sq ft (11' 3 1/2" x 12' 9 3/4") 127.99 sq ft c�
1_ CLOS
N - 1.1' 3 1/4" x 11' 4 1/4" *-
T
HALL
25.30 sq ft (3' 2" x 8')
1 DIN _
LIVING ROOM '
121 .16 sq ft FI E PLA
236.13 sq ft.(11' 6 3/4" x 20' 5") .
11' 6 1/2" x 10' 6"
N - _
110'.6" 20' 5"
Y
_ 101 8, ,
c
CLOSET
BEDROOM
co
93 .59 sq ft o
8' 1 Ill x 10,: 6"
i
THROO
zo
co
OTHERk T _
� M 31, 3 -88:-8qft
-t
10' x 3 1 ' .4 3/4
c � I'c ,
(,A Ce --
' 'BEDROOM
121 .12 sa ft
Co
81 11 11X13-1 71
CLOSET
10' 8
�--- CA
` -
11 41/2 11 3
WORKSHOP STORAGE
1 127.85 sq ft 126.49 sq ft "'
11 ' 3" x 11 4 1 /2" 11 ' 3" x 11 ' 3" r
.€�_-. . .•��:�. -,„,.e.u gV': -�,';�-.T!4:•!-,i r'-a:3--... .,,..._....-a+.• .i....+ -.. .aye '�,,..�` -�;_ .:s� - ra. .. ..-��r .- . -. _- -_.� __ ,. - - ....+..,,,�'
r _.. /PD
1
STORAGE
co
280.07 sq ft (13' 6" x 231)
C
ATH ROO �"'
- T
o
i
t i 8, 8„
4' 1 /2"
t
r(I ��
11" 4 1 /2"
WORKSHOP BEDROOM
1 - 127.85 sq ft 126.49 sq ft "_'
11 ' 3" x 11 ' 4 1 /2" 11 ' 3" X 11 1 31' FIN
CD
t •4 _ ,mm,• F.� - ti..>'T '�.- ''+,. •-'c- _.. —�' _ ," - _ _ "''V.'���.. -_ .. _tea•, r •l 1.
1�
1 DINING ROOM
280.07 sq ft (13' 6" x 231)
1 ATH ROO co
' 181811
• - 4' 1 /2"
N SITE PLAN Design Calculations ROUTE 28 - N
SCALE: 1 "=20'
BENCH MARK ON TOP OF CONRETE SLAB Number of Bedrooms: 3 Existing + 1 Proposed= 4 Total
AT GARAGE DOOR ELEV.-100-65' (ASSUMED) Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN
Septic Tank Capacity Required: 440 gpd X 200% = 880 gpd
Septic Tank Provided: 1,000 gallon
71 Leaching Capacity Required: 440 Gal./Day
2RQPQ5EQ
_5M Leaching Area Required: 440 Gal./(0.74 Gal./Sq.FQ=595 Sq.Ft.
12.51 X 9'W X 2.0' D
(0 leaching trench using 1 H-10 Existing Leaching Structure: 2-34' X 2' X 2' TRENCHES = 424 SQ. FT. 314 GPD C,
500 gal. chambers with 2' of Proposed Leaching Area Provided: 12.5' X 9' X 2' = 198 SQ. FT = 146 gpd.
stone on sides & ends. Total Leaching Capacity. 460 gpd > 440 gpd. req'd.
#65 K�LLt
GENERAL NOTES "HYANNIS"
W/carban fltw, X RQAt) 1. ADDRESS: #77 KELLEY ROAD
X 100,86, 2. ASSESSORS NUMBER: 292-192
ea 3. DEVELOPER'S LOT: LOT 22A LOCUS
00.45' Septic
0 06. 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN NO SCALE
ON THE GROUND INSTRUMENT SURVEY.
AR&4
5. TOWN WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES.
6. REFERENCE PLAN: PLAN BOOK 245 PACE 141
REFERENCE PLAN: *MORTGAGE INSPECTION FOR CRESCENT MORTGAGE
.......... ............. BY YANKEE SURVEY CONSULTANTS, DATED 6/24/98.-
7. NO WETLANDS ARE LOCATED WITHIN 200 FEET OF SAS.
8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS.
Meter
1001(y 9. THIS PLAN WAS PREPARED FOR THE SEPTIC INSTALLATION ONLY.
�_NG SAS99,07' 10. THE SITE IS NOT LOCATED WITHIN A ZONE 11 GROUNDWATER RECHARGE AREA.
2-341 X 2'W X 2 0' D
11. THE LOCATION OF THE EXISTING SEPTIC SYSTEM WAS REFERENCED FROM J.P. MACOMBER
SEP11C INSPECTION DATED 4/27/2005.
lip ................ CONSTRUCTION NOTES
13.M. I Contractor is responsible for Digsafe notification
and protection of all underground utilities and pipes.
2. The septic"tank a7q distribution box shall be set
level on 6 of 3 4 -11/2" stone.
a 3. Bockfill should be clean sand or gravel with no
stories over 3" in size.
W- LOT 2 A 4. This system is subject to inspection during installation
0 by Glen E. Harrington, R.S.
.ei-
37' AREA 16jai .383± SQ-FT- 0 5. The contractor shall install this system in accordance
with Title V of the Massachusetts Environmental Code
0-
c and the Regulations of the Town of Barnstable.
=40' 6. Provide ONE Acme Precast H-10, 500 gal. chamber or equal.
7. No vehicle or heavy machinery shall drive over the
septic system unless noted as H-20 septic components.
(% F� ` 8. Install as baffle or equal on septic tank outlet tee end.
64- 100,47' Lu 9. All existing inverts and site conditions shall be verified by contractor.
10. The existing SAS shall not be disturbed upon excavation of new distribution line or proposed SAS.
#85 ,�OAD
WC?
9m, I-W 01AX AOMIS MAI*=
PERK TEST & SOIL EVALUATIONS
DATE OF PERK TESTS & EVALUATIONS: OCT013ER 28, 2005 5'
TEST PERFORMED BY:DANIEL B. JOHNSON, R.S.
WITNESSED BY: Donald Desmarais R.S. Bamstable Board of Health Inspector 100.04'
EXCAVATED BY: D.A. BROWN LANbS64ANG � LLL/// j��
PERK NO. P11160
PERK RATE: LESS THAN 2 MPI ASSUMED C3
EEEK TEST 0 T.H. ;01 34*
Test Hole Test Hole 1 PERK DEPTH-36--5e- (CI) C3 C3 r-3 C3
No. 1 No. 2 BEG. SOAK 0 11:08 AM
END SOAK 0 11.15 AM SIM REIMRCED
DEPTH SOILS ELEV. TH SOILS ELEV. 24 gals applied within 15 min. I H-10 500 gal. chamber
USE PERK RATE < 2 MPI FOR DESIGN PURPOSES ND-5ECIION
o ® PLAN VIEW
A H-10 500 QALLQ-N--2JAMBE
W,-LL 11 tm"y OWW
10"_ 10*3/2 100- 4 _j--2_,1- PEEK TEST-9-Lfl,-JZ NOT TO SCALE
ow Sw WAIVED BY AGENT OF BOH.
32* 3W USE PERK RATE < 2 MPI FOR DESIGN PURPOSES USE ACME PRECAST OR EQUAL
ci ci
me&-=WWI
nwd-m MW
-M wow
13
NO GROUNDWATER ENCOUNTERED ,A PROPOSED SEPTIC SYSTEM UPGRADE
PREPARED FOR
D.A. BROWN LANDSCAPING
HARRIFITON
AT
LEGEND 070 #77 KELLEY ROAD
G S I
PERCOLATION TEST LOCATION 9tvJTAR\P BARNSTABLE (HYANNIS), MA
10' min. from *NOTE ALL PIPES ARE TO BE 4* DLk SCHEDULE 40 P.V.C.
house to sciatic tank ftyide 4'dia. SW 40 Pvc vent wfth*aim Mar EXIH-10 SEPTICSTING 1000TANK GAL PREPARED BY:
EXISTING FEE
Existing House 5 HOLE H-10
LX)STAIG GRADE MT. BOX Finished grade *ver_9**m-2% slope away Exbftg Craft 0w-1MV* DENOTES EXISTING GLEN E. HARRINGTON, R.S.
Provide riser to within 6' of grade min. 21-111r-11r Provide"riser to 12" min. SPOT GRADE 9 LEDA ROSE LANE
fu S-.01 U" for 2' dotMo-washvo Slone ith;l:n�" of grad ' max
33. EXISTING 3 .01 95- EXISTING CONTOUR MARSTONS MILLS, MA 02648
cellar 1000 GAL 8-
62 .9f
A SEPTIC TANK nv. elev.- 96.76' DEEP TEST HOLE TEL: 508-428-3862
711 H-1v Em - - - '
Ex. Inv. elev.=97.68' am a Inv. elev.=96.54' 126V- irench Bev.= 93.92'
OMR---AL Inv. eley.= 9 FAX: 508-428-3862
Inv. elev.=9 .01 3,4L 1:r a 1ustwd APPROX. LOCATION '
e OF 3/4:'-1 1 1/2'1 STONE .tone LEACH TRENCH EXISTING WATER SERVICE
Iny. g1lay.= 95-92 yBottom of T.H. #2 elov.-88.95' SCALE: 1 "=20' DRAWN BY: GEH DEC. 17, 2005
e- r- APPROX. LOCATION
-5y5T M--PROEILE 8-OF 3/4--'Ii/r STWE EXISTING GAS SERVICE
Not to Sods DATUM: ASSUMED FILE: BROWNKELLEY SHEET 1 OF 1