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HomeMy WebLinkAbout0007 KITSY LANE - Health 7,Kitsy Lane r Hyannis P A = 251 186 e 0 0 i 1 e I� Commonwealth of Massachusetts asp -/S0 �w Title 5 Official Inspection Form il += l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 9 u� 7 Kitsy Lane Property Address t ' Wanderley Silva ; 't Owner Owner's Name information is /H annis V MA 02601 08/10/2020 required for every y page. City/Town State Zip Code Date of Inspection tt 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 '570 ILI 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 r� Company Address Teaticket Ma. 02536 Cityrrown 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 08/11/2020 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts ,(,p Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 4 bedroom home has an H-10 1000 gallon septic tank feeding 2 leaching pits. At the time of the inspection no visible failure criteria was found. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �� - p Title 5 Official Inspection Form k �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Kitsy Lane v� Property Address Wanderley Silva Owner Owner's Name information is Hyannis MA 02601 08/10/2020 required for every 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): ❑ broken pipe(s) are replaced ❑ Y- ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if , the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 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 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. Cityrrown 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: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is Hyannis MA 02601 08/10/2020 required for every H-y . 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 %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. El ® 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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 ,�-p Title 5 Official Inspection Form IF 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane u� Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: r� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts 19J. _, Itip Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ;w ,T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 24" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon i 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 34 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 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 liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ,(,A Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /I 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis annis MA 02601 08/10/2020 page. Citylrown 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 of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. Cityfrown 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 N/A 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.): ran a camera down the pipe and did not see a D-Box. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 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: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.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 I, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 7 Kitsy Lane i L. Property Address Wanderley Silva ` Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the first pit was at working level and the second pit had 12+ inches available and no visible failure criteria was found. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane V Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): II t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of'Massa � 5 chusetts Title Official Inspection Form Subsurface Sewage Disposal I Kits Lane system Not for Voluntary Assessments Property Address Owner v;nv le Silva information is Owner's Name required for every Hyannis page. UlYfrown MA 02�C_ode �_D�ateln�spection Sta a ZipZip�• Systelm Information (cont.) 14. Sketch Of Sewage Disposal System: t landmarks or benchmarks. Locate all wells within 100 feet. Locate the building. Check one of the boxes below: at least tw Provide a view of the sewage disposal system, including ties ° o permanent reference e where public water supply enters hand-sketch in the area below ❑ drawing attached separately I 0 0 I i � L p J1 I 7• i r pyr L t • i t5insp.doc.rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 g i Commonwealth of Massachusetts -. Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 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 and shot it with a transit. 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 �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane V� Property Address Wanderley Silva Owner Owner's Name information is required for every Hyannis MA 02601 08/10/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts k W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessm e, t� ,M 7 Kitsy Lane. Property Address. Periera �s Owner Owner's Nam r. information is required for every Hyannis17 MA 02648 July 9, 2015 ^c page. City/Town State Zip Code Date of Inspection h� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information r on the computer, C{ 0 f use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason r� Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 9, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 7 Kitsy Lane _ Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every _ y Y page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. Change in use may lead to hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below).- distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. I For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane _ Property Address Periera _ Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every Y Y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions depth of liquid, depth of sludge and de th of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the.Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every Y Y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: 2013; 8,600 gallons and 2014; 20,300 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): — — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Periera Owner Owner's Name information is i anns MA 02648 Jul required for every Hyannis y 9, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every Y Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 inches feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: eet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 15 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Risers within 6 inches of grade. Effluent level with outlet tee. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical offSludge depth: l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 47 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Tees are pvc. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 7 Kitsy Lane _ Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yens ❑ No I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9 2015 required for every Y Y , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No distribution box present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is H annis MA 02648 9, 2015 required for every y July page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no standing efluent in the leaching pit at the time of inspeciton. No excessive vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cwM 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every Y Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Kitsy Lane M Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 7 Kitsy Lane Property Address Periera Owner Owner's Name information is Hyannis MA 02648 Jul 9, 2015 required for every y Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION K.ithy Zane SEWAGE# 912103 VILLAGE fLyannih,Nahh. ASSESSOR'S MAP&LOT251-186 INSTALLER'S NAME&PHONE NO. 7.P,Ra c o m 9 e 4 14. SEPTIC TANK CAPACrrY _1500 ga P B o n h CHING FACILITY:(type)2-LP-1000'h (size)3000 ga22onh OFBEDROOMS 3 BUILDER OR OWNEROi_$P.iam Schui.tz Inhlzection. PERMITDATE:9/210 3 COMPLIANCE DATE: 912103 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 feeubf leachi f li II��' Feet Furnished byy � �ofrdC o 7• y http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=251186&seq=1 7/13/2015 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.] You must first obtain the necessary signatUres on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. Z0 �\ r ,. � DATE: - Fill in please: I C APPLICANT'S YOUR NAME/S: \l�il)G� I w t I ���� ,C �? BUSINESS YOUR HOME ADDRESS: K I T u L to i 5 AY ,l 33 TELEPHONE # Home Telephone Number 5c�' ZqQ 9 3 3 NAME OFiNEW BUSINESS �O LQ(�' Vy O(� KS`i �r"-�.1 �fi, 1 �G� TYPE'.OF BUSINESS �� 1 ti�i�-�F- IS ADDRESS'OF;BUSINESS- TS -N 1� tJ.I. I^'l MAP/PARCEL NUMBER �. �. (Assessing) When starting a new business there,are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. L Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has then i fo d/¢jf ghe permit requirements that pertain to this type of business. MUST�ZMPLY WITH ALL l� V 6� � 4AZARDOUS MATERIALS REGUI_ATI01►S Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: c+ tt Date:o /22_ TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: CbCO '2 tip Z (-'S 1?0- i N 1 ti BUSINESS LOCATION: "2 K I 5- - -1 C N INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 5'6'P ZVO -) 4 33 CONTACT PERSON: Q Ac D ( u C- i 7l la N 9 C c-D EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: ra 1'N fv- k AJ G INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) \ 1 Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's v S Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, \ Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes ` Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash 1, WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials DATE : 912103 `SFPj92 PROPERTY ADDRESS: 7_Kit�srLane-------_-- ------ -royFOp 003 -- - l q�T ST l'l-------------- --M.U------------- --- On the above date, I inspected the septic system-at the above address. Tnis system consists of the following: 1. 1- 7500 ya2.(on zept.ic tank. MAP 2. 2- 1000 ya-Rion /22ecazt feach.ing p.itz. 3. 1-D-i-6ta ittut.ion Sox. PARCEL 8asea on my inspection, I certify the following conditions: LOT s� 4. 7h.ie .ih a t.itie Jive hept.ic system. ( 78 Code J 5. The aept.ie zyztem .ih .in /22o/2ea wo2k-ing oade/z at the /2aehent time. 6. No need o� any ae/2a.iaz at thin time. SIGNATUR /!7�� Fame _ J P . _rtacomber Jr . Son, Inc . - ------------ - - -(Z-e-ns.e.YLLLP,_ �ja _ _QZ632- 0066 p^one - -508 . 775_ ) 3 )8 --- - - --- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ' )OSEPH P. MACOMBER & SON, INC. T ink s-Cesspools•l.eichflelds Pumped & Instilled Town Se-ger Connections P 0 Box 66 Centerville. MA 0263?•0066 ]]5.3338 775.6412 , f ,per �-\ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 -�" OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PA RT A CERTIFICATION Property Address: 7 Kpi-.6y Lane Kyann.iz Plah.s. Owner's Name:U-i..r?r?.am Schu.P z Owner's Address: Same Date of Inspection: 912103 Name of Inspector: (lease print) ao,3e/2h P. Nacomge2 a/z. Company Name:.• / . t�acom e2 9 Son Inc. Mailing Address:9 o x 66 Cen; e2y.i.i.ee, Nazh. 02632 Telephone Number: 5.0 8-7 7 5-3 3 3 8 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: 7 ,4 The system inspector shall �/Mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 K.itzy Lane Kuann-.e, Na1se. Owner S ehtuLi.r z Date of Inspection: 912103 , Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 6ystem Pas I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated below. Comments: The zeRt ie 1,yb en2 .cz in /2,co/2e/z TjZ:7:747FF7g 32 e a e /2 2 e.a e rt.t time. B. System Conditionally Passes: Alb 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. ,(/D The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 1Q) Observation of sewage backup or break out or high static water level in the distribution box due to broken or obsncted 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)arc replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)arc replaced obstruction is removed ND explain: 2 Page 3 of 1.1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Kit-6 y Lane 8ya/Znt.6, a,6,6. 0woer4l.iii.i.arn Schu-etz Date of Inspection: 912103 C. Further Evaluation is Required by the Board of Health: 110 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. I. S}-stem 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; VO Cesspool or privy is within 50 feet of a surface water ,2 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: Ve 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 _ s a septic tank and SAS and the SAS is within a Zone I of a public water supple. 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 109�feet but 5q feet or more from a private water supple well—. Method used to determine distance 'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached.to this form, 3. Other - 3 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 Ki. by Lane Kyann-:z, Naz. . Owner: N-iieiam Schanz Date of Inspection:' 912103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes Y/Discharge ' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool �/ Static liquid level in he distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ,2„( IP4615 _ // squid depth in.cesspcol is less than 6"below invert or available volume is less than i4 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 0 . _ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or.privy is within 100 feet of a surface water supply or tributary to a surface /water supply. /Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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" to Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION CORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Kit,3 y Lane yannz . Owner:u,,,PPj am Schu 2tz Date of laspectioa: 912103 Check if the following have been done. You must indicate"yes"or"no" as to each of the following Yes No ///Pumping information was provided by the owner, occupant, or Board of Health G� Were any of the system components pumped out in the previous two weeks — Has the system received normal (lows in the previous two week period ? _ YHayc 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? I/ _ Was the site inspected for signs of break out ? z _ Were all onents System com ,Y p -e�cluding 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 maintenance of subsurface sewage disposal systems ? )Provided with information on the proper The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no — ✓ Existing information. For example, a plan at the Board of Health. _1//_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' Property Address: 7 Katz y Lane yannT6, 1776. Owoer:b)-i-e-tiam 3chultz - Date of Inspection: .912103 RESIDENTIAL FLOW CONDITIONS �,.:,... Number of bedrooms(design):', Number of bedrooms(actual): DESIGN now based on 310 CMkIS.203 (for example: 110 gpd x M of bedrooms): &X/ 04G'��1� Number of current residents: Does residence have a garbage grinder(yes or no):ND Is laundry on a separate sewage system`( or no):,S (if yes separate inspection required) Laundry system inspected (yes or no �I Seasonal use: (yes or no): ALSO Water meter readings, if available (last 2 years usage (gpd)): 2002=14 9, 250 ya e.Pona=408. 91 qPD Sump pump(yes or no): 4,b 2003=190, 000 yaieon,6=520. 55 gPD Last date or occupancy: COMM ERCIALANDUSTRIAL Type of establishment: .-M Design now(based on 310 CMR 15.203): AM gpd Basis of design now(seats/persons/sgft,etc.): N Grease trap present(yes or no):leg Industrial waste holding tank present(yes or no):40 Non•sanit.ary waste discharged to the Title 5 system (yes or no):,f Water meter readings, if available: ) Last date of occupancy/use: OTHER(describe): 160 GENERAL INFORMATION Pumping Records Sourcc of information: 44y(, Was system pumped as pan of the inspection(yes or no):/,2 If yes, volume pumped: 4 Qallons -- How was quantity pumped determined? Rcason for pumping: TYP�F SYSTEM Scptic tank, distribution box, soil absorption system e Single cesspool ,da Overflow cesspool /Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank ;'Yi9 Attach a copy of the DEP approval — PP Other(describe): Approxima a aec of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site (yes or no)ell!:h 6 Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: K-it-6y Lane yann.iz, 11azz. Owner: bl.iiP.iam Sehuftz Date of Inspection; 912103 r- BUILDING SEWER(locate on site plan) 4" -tire wie yht PVC �f Depth below grade: PIP6 78ROUGh out .the /� Materials of construction_ ast iron A_40 PVC`/other(explain): Zy,6I-em Distance from private water supply well or suction line: le � Comments(on condition of joints, venting, evidence of leakage, etc.): go-int.6 'a eat yuh� # No Pv /rnnrn -Q,4 Yjrz 4yv 7he. .6y Pin t6 vented ..th2ou/yh .the aoo� vent. d SEPTIC TANK: (locate on site plan) if—M Depth below grade': Material ofconstructIon:/concrete4_metal.�fiberglass�olyethylene n� other(explairt) If tank is metal list age:1�4 Is age confirmed by a Certificate of Compliance (yes or no):40 (attach a copy of certificate) �� / Dimensions: " 57�/1 Sludge depth:;�,.ei Distance from top of sludge to bonom of outlet tee or baffle: ZeA—,,A . Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bottom�f outlets tee orbaffle: How we're 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.): Pump .the ae4?t.ic .tank eve2u 2-3 ueaaz. In.Pet 9 out.Pet teen ate .in •RPace The .tank j., ',,tILuctu2a.PPu wound and zhow16 no evidence of Peakaye:Ligu.id Peve.P at the out.Pet tnveat i,6 51" GREASE TRA (locate on site plan) Depth below grade:. Material oPcons7uction:,O—concrete4kmetaLf/9 fibergla.*l polyethylenc-W other (explain): Dimensions: 116 Scum thickness: 4 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: _AL Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to.outlet invert, evidence of leakage, etc.): tI?vn.ty {17n,2 Ls not f121ipApnt I Page 81of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: K it.,3 y Lame Kyarcrz.i�, ('lci��s. Owner: Snhuiiz Date of Inspection: 912103 TIGHT or HOLDING TANK4,a(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: .)17 Material of construction: 141qconcrete 114 metal.!/,f fiberglass,& pol.yethylene,60 other(explain): Dimensions: Capacity: gallons Design Flow: Ao gallons/day Alarm present(yes or no): 4,114 Alarm level: A* Alarm in working order(yes or no): Date of last pumping: Al/$ Comments(condition of alarm and float switches,etc.): 7-:glz.t o2 hoCding .t<ank.6 ate no.t p2e.6ent. DISTRIBUTION BOX: !/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBEWkL(locate on site plan) Pumps in working order(yes or no): AM Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Luala r-hamPvn i,6 noi pzg,3pnf 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 K c.t s y Lane Kyann.ih, /'a.3,3. Owner: Q.i tiara Schu-ftz Date of Inspection: 9/210 3 Zlo-cate SOIL ABSORPTION SYSTEM (SAS): on site plan, excavation not required) 2- 1000 as-Pion /22eca,3 .t?eachina 12.it6 If SAS not located explain why: Loca eSee /2aye 10 Typfe ,S ✓ leaching pits,number:,;:- ,tPl?v leaching chambers, number: D _ leaching galleries,number: leaching trenches, number, length: 6 leaching fields,number, dimensions: overflow cesspool, number: innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy .6and to medium 4ine band. No e.ignz of hydlLauii.c )eai..9uze 02 .1?onrJ na, n y C11LU, VP-gPtrrtinn t.,6 noarna'e.. CESSPOOLS(,(cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet invert: Depth of solids layer: WX 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.): rv.t.tnnn,P,A rino nol 12nn,tvnt PRIVY�e— (locate on site plan) Materials of construction: Dimensions: Depth of solids: _ & Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 k. t.6y Larne yarnrnt,3, a,6,3. Owner:l--i,e,iam Schuetz Date of Inspection: 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. 0 0 r i ) 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: K i._e y Lane flyanni,6, Na3.6. Owner:O.ii iam Schu.P.t_z Date of Inspection: 912103 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 ' 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: NA _qESObserved site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NA $Checked with local excavators, installers-(attach documentation) 4ESAccessed USGS database-explain:/,f f p, //f own P.riQnAiag Pe. ma. u.6. You must describe how you established the high ground water elevation: sed: Gah2etu 9 MiUea Nodee. 12116194 �/zound waz`_e2 e.Peva.t.ion.s aPove .aea PeveP. sed: 12SGS 09,ig2vat /on zo .P- cIrzin. �uno 1992 ied: IZSGS !7orhnira2 PuZZeL n 92_bOO 1 102nio #2 Annual- 1?nnws o4yl?ound n n.Qounfinnw Leaching �V Pit 'cc( Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottof� Of the leaching pit and the adjusted groundwater table is I% feet. I1 ( •r.wn r'+T-nITR—.-Titan:ww•nawn.-rnTa�rT.�.rlvw+w+nrTnrTawRIr�T�y t'T�'wT�n win .. B a 2 n z i-a gig TOWN OF UOARD OF HEALTH SUI)SURFACE SFWAGE 1)18f'O,SAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION ^•Tt`1�T"•",�T.1 IR�.tTTl�1a!all'I1.1fa1^lrJ'n/Pa"tRT.T—t'I "1,RR7• ��TL.�<���R\ aunt -TYPO OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 7 K.i.t,3y Lane Ryannih, Na.3.a. ' ASSESSORS MAP, BLOCK AND PARCEL # 47 OWNER' S NAME Gl.iii.iam Schu.P.tz t� PART D - CERTIFICATION NAME OF INSPECTORJoseph P. Macomber Jr. COMPANY NAME J P Macomber & Son Ind.` COMPANY ADDRESSBox 66 Centerville Mass. 02632 strelt To vn or City Stat• C!P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 CCRTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one ; /System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heRI L11 or the environment as defined in 310 CMR 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection wh► icll I have condDicted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of- this inspection form , Inspector Signature a Date ne copy of thi certification must be provided to the. OWNER, the BUYER ( where applicable ) and the I30ARD OF HRALTH. * If the inspection FAILED, the owner or""operator shall u d within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 15 , 306 , partd . doc E 1:2 �->1 4-t, _F - CD f '7 s ;C f I a �A3 So'�J i' )-,)A.+ `J [r Cad.Je-4 /Y--" J SF rl i TOWN OF BARNSTABLE LOCATION 7 Kit,3y .eane SEWAGE # 9/2/03 vhLLAGE hyann.c s, Na,3,6. ASSESSOR'S MAP& LOT251- 186 INSTALLER'S NAME&PHONE NO. 7. l/. 17 a c o m 9 e 2 �2. .SEPTIC TANK CAPACITY 1500 ya U o n z 2-Li-1000' zs sze 3000 yaiionz LEACHING FACILITY: (type) ( i ) `[ O.OF BEDROOMS 3 Inh/�ec.z<�oiz. BUILDEROROWNER Witiam Schuitz PERMIT DATE:9%2/0 3 COMPLIANCE DATE: 9/2/0 3 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 leachi g f lity Feet Furnished b M e / NI s / r s LOCATION - SEWAGE PERMIT NO. VILLAGE :A & B CESSPOOL SERVICE 'P ,.28 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER 1/ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � / I i�' � _ a i -,� r_ /� �, �� � , � � �. ��t � .. �� -.�] �. �."` DO No....$? .1 �•-- Fps ...15.00......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town............OF............Barnstable ............_.. ........................ ... Appliraatiaan for Dispaas al Varkii Tomitrurtiaan ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: Lr3dlsw...¢.........-H.Yanniz_,__M.....D2.60l.......... .................................................................................................. Location-Address or Lot No. ............. --....---•---•----------------•--•--------- -Kitse3r.Zaxie., ,.. _...426�1�-----.............. Owner Address W A & B-•Cess l._ .x'���� �..................................... 128--lisha s Texxace 1 a nds- 1 ••---•--.....-•--•--- ........... p ... 3� Installer Address Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms................3..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................ •-----------•---------------••-----•----•---•----------------------•-----•-•--------------•---•------.....•...------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter._.__-_--___-.-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ......-.............................................................................................---••--•-------••-----....•-----------------........---- Descriptionof Soil Sand------------------------------------------------•------------------•------------•-----------------------------------•••------..-•--- x w o s—Answe when applicable...i -------------------------------------------------------•---- V Nature of RRe it or Altera installation of 1,000 gallon, p c� re-cast tone packs each pit (overflow� . -------------------------------------------------------------------------------------------------------I=--------------------------------------------------------------------------•-••-----•-•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with . the provisions of TITI.i� 5 of the State Sanitary Code— The undersig f l:er agrees not to place the system in operation until a Certificate of Compliance has i 9u by the boa, of lth. _ r � Signed.. ... . �: '..02/12/85 -�. �/� Application Approved BY 02/'� �85 Date Application Disapproved for th following reasons:.............................................--------------------------------................................. --•-•........................•---•----•----------....------......•--------•------------•---•----------------•----------------------------------------------............................................ Permit N85..............� 1 / I - - Issued 02--12/8,r -Date Date No....W .. ..... FEB$...15.QQ......._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... Town.............oF...........BarWtl ble-.------------...._...-•-----------•-----•--...... Atipfiration"or D*agai larks Tututrurtion rrmit I r r Application is hereby, made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal 1 System at: 7.--XitSe-Y- ®---r-.....•--•I�ya�rn�� P�4 42641........... ........•-•-------------------------•-------------------•---•----•--------.......--•------........ Location-Address or Lot No. J&MS..Sahu7 SahUIU---------------------------------------------------------------- '�Z•�i#tS8* i,e�tie� �lya7t aas�s-P9a�....f}`Z,6ff'1_......---....----- Owner wA L t -In4---•----------------------•--•----• 128 3�i� Installer .. @ r .._.H ni ._ �_... Addr s UType of Building !� Size Lot............................Sq. feet Dwelling—No. of.Bedrooms...............3..........................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons...................'__._..... Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes'per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� ...... ----•----•-----------------------------------------•---------•.....-----•------•-•---•-••-•--•-••••-----•-••-.....•-•••------------•••••••••._.....-- O Description of Soil.........................Sand x ............................------•---••-•-•--....---------------------------•--..._...------------•-----•--------------------•.......-------- w U Nature of Repairs or Alteratio s—Answe when applicable__ stone packed leach pit (overflow. -----•-••-- -------------------------•---------------------------------------------------------•------------•--.......__...-•=••----- Agreement: The undersigned agrees to install the aforedescribed ,Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code.:— The undersi f ther'agrees not to place the system in operation until a Certificate of Compliance has i e by fhe boa of alth. Signed -_���-ter - -------------------- Application Approved By...... • --------•- �*��--'---- -•.' ---�----•-......_..__ 02�078 __.. .. Date Application Disapproved for a following reasons:--------- ------------------------•---------------•--......................................................... ................................................:...................................................... - ................------------------------------------------------------------•-----•--•••- Date Permit — ___. Issued____________ 02.................12/85 I5. ^._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t ........................Town.......OF....V Ba:rnstable........................-----.................... Trdifarate of Tantpliattrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) by... .__A_&B Ces __ sp000l 4ery ce, Inc .. 128 Aishops_ A:...Q 601---•--•------------ Installer at...7 Kitsey Lane, Hyannis►•�?A__• 02601 -_James,.Sc.h..u1tz..............................................................................---- - - ...... ...-- . has been installed in accordance with the provisions of TI LF j o�j e State Sanitary Code as described in the- application for Disposal Works Construction Permit No....�5................ ....4_-----_ dated-----2/12/85.......................... THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUAR TEE THAT THE SYSTEM WILL POWICTION SATISFACTORY. ...., DATE... 2/12/85........................................................ Inspector Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH g - ..................Town.............OF..............Ba=jatable............................................ A. No.......................... FEE.................Q...1>.00 Permission is hereby granted............ A & B Cesspool__Set! e, ........................................................... to Cons ruct ( ) or Repair (X ) an Individual Sewage Disposal System at No.....Kitsey Lane, Hyannis PIA 02601 James-,Schutz reet 85 as shown on the application for Disposal Works Construction Per -t No..._.__ � D ed-- ____ 12/_--------------- (/✓�.1. ... 7. 'r' V7�.J � b),of Health � DATE --- :.-. �� FORM 1255 A. M. SULKIN, INC.,-BOSTON - -,