HomeMy WebLinkAbout0393 LINCOLN ROAD EXTENSION - Health 393 Lincoln Rd Ext
Hyannis
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Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is required for every Hyannis Ma 02601 10-22-2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information S I 1- q:i',3
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
r�oo (508)477-0653 S113747
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
Brett Hickey „^ Hickey
Datw.202o10 31733:42-04'00' 10-22-2020
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.
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis ,
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
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:
The two cesspools and leach pit in series were in working order at the time of inspection.
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):
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is required for every Hyannis Ma 02601 10-22-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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:
t5lnsp.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
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- 393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El 0 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
15insp.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
At /�
�
(
�,� 393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4 Failure
System
y a lure Criteria Applicable to All cont.Systems:Y (cont.)
Yes No
❑ O 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 '/Z day flow
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ E] 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.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.
❑ El 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
t51nsp.doc•rev.7/26/2018 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
' 393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every Y
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
❑ E - Pumping information was provided by the owner,occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
❑ 0 Has the system received normal flows in the previous two week period?
ElHave large volumes of water been introduced to the system recently or as part of
El this inspection?
❑ O Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
R ❑ Were all system components,excluding the SAS, located on site?
0 ❑ 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?
❑ a 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:
❑ El 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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
No design plans 3+office space
Number of bedrooms(design): Number of bedrooms(actual):
NA
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
No design plans or permits available at Board of Health.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes Q 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 0 No
Seasonaluse? ❑ Yes Q No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
*** 2019-2,992gallons 2020- 3,000gallons ***
Sump pump? ❑ Yes ❑■ No
House not used.office only
Last date of occupancy: Date
t5lnsp.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
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Office
Type of Establishment:
No design plans
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 0 No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes. Q No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes No
Water meter readings, if available:
Last date of occupancy/use: currentlyDate
Other(describe below):
3. Pumping Records:
Source of information: Owner-date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Cesspools not pumped as they were dry
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every
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.
El Other(describe):
Cesspool, cesspool and leach pit in series
Approximate age of all components, date installed(if known)and source of information:
unknown due to lack of record
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan): _
3'
Depth below grade: feet
Material of construction:
❑cast iron OR 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting,evidence of leakage,etc.):
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
NA
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
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: NA
Material of construction:
El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5lnsp.doc-rev.712612018 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
3-
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches,etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
NA
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�y Title 5 Official Inspection Form ,
` tz
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every
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.):
NA
*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:
(1) 6'x6' pit
El leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
- 6'x8'
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t51nsp.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
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
pace. 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.):
Over flow cesspool and overflow pit were both dry and in working order when viewed.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 2 in series with a leach pit
Depth—top of liquid to inlet invert Both dry
rr n
Depth of solids layer
n n
Depth of scum layer
Both 6'x8'
Dimensions of cesspool
blocks
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.):
Both cesspools were dry when viewed.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
vw393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
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
p Title 5 Official Inspection Form
I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owner's Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
Route 28
I>
( l
;OveMpg
c A B
0
j
IR
n
d.
Cesspool
. ....,E
z 2
C s al A1.2T'
I: A243'
A3.40'
B1.38`
B2.2T,
X Pit
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address .
Ed Janulaitis
Owner Owner's Name
information is Hyannis
required for every y Ma 02601 10-22-2020
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: NoGW@12'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
El Observed site(abutting property/observation hole within 150 feet of SAS)
i
El Checked with local Board of Health-explain:
see below
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A town topo map was used to determine high groundwater. High ground water is
greater than 12' in area. A hand hole was also augured 4 below the dry leach pit and
no water was encountered.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51nsp.doc•rev.7/26/2018 Tiffs 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
uw Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
393 Lincoln Road Extension
Property Address
Ed Janulaitis
Owner Owners Name
information is Hyannis Ma 02601 10-22-2020
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
i
�■ A. Inspector Information: Complete all fields in this section.
❑■ B. Certification: Signed&Dated and 1,2, 3,or 4 checked
W■ 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
t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r �w
t YOU.WISH TO OPEN A BUSINESS? o f�-r/d
For Your Information: Business certificates (cost$3 ea 0 f_or 4 y rs). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission .o op.. ate.j Musi ess Certificates.are available at the Town Clerk's Office, 1 'FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: `1 5110
Fill in lease:
APPLICANT
p M,4RT1X1,4� SLIS',RS
APPLICANT'S YOUR NAME:
BUSINESS YOUR HOME ADDRESS: E&�> "; 1-1you r1le_
u '
TELEPHONE # Home Telephone Number lG����� '-�'S7
NAME OF NEW BUSINESS.. IARTY.;S LO /J'T,/CS TYPE OF BUSINESS Dt I► P.o .
1S THIS:A HOME OCGUPAT YE5 NO
Have you,,:been'given aPprovahfr.o thn uiJ wisip NO
A.DDRESS OF BUSINESS Sty--� _ ti MAWPARCEL NUMBER_. a ' — D�
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.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual has bee ermit requirements that pertain to this type of business.
AjdChorized Signature*
COMMENTS: . e o 2 a.+-ems
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
I
Authorized Signature*
COMMENTS:
TOWN OF BARNSTABLE Date: 5 /31 / oG
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS:
BUSINESS LOCATION: �� 't'a� �y o ,�yaNN�J' , �/,¢ �26�/ INVENTORY
MAILINGADDRESS: - �' 3 L'v�colrt Q�� TOTAL AMOUNT-
TELEPHONE NUMBER:
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: -Z),�r2lWf)y 142y-"
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 materials 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) Misc. Corrosive
p( NEW USED Cesspool cleaners
J" 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)
h
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
I�
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor&furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers -2
(including bleach)
u
Spot removers &cleaning fluids
F
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash 6/
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
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TOWN OF BARNSTABLE
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MARESTA3LL i
p�Y&r�� BUILDING INSPECTOR
APPLICATIONFOR PERMIT TO ..................................................................... ......................................................
' .
TYPEOF CONSTRUCTION ..........s :�e�.......:.......... .,,....................................................................
......:..:....................
... /...............19�17 e
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for yak permit according to the following information:
Location ..... v.... :. 2 '°�. °... ..£... {> zv" t. . y �^1. ..................................
Proposed Use ........ P
.......... ...........................................................................................
Zoning District .....� °..../............................................Fire District
Name of Owner .........................kr !'/ 1 .....Addr f�.. ...............................................f��'°�` JY�,?� r `�..e. . x...
Address 4 '`
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
.Foundation ( � ° ° �.� ..
Number of Rooms ..... .......................................................... �. .................... ........ .................................
Exterior ... r� dt� ..... ' � .................................Roofing ✓ aC:.*� � / u.... P Oita : ....................
Floors .... ...............................f fi....:......a .:.................Interior ....................................................................................
Heating ..... G. ........................................................Plumbing . . � e ........................................................
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Fireplace .........:. .....................................................................Approximate Cost ...... ...................................
Definitive Plan Approved by Planning Board -----------_-----__---------19 . A/-'
Diagram of Lot and Building with Dimensions
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SUBJECT TO APPROVAL OF BOARD OF HEALTH /
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! ' ® 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
z, construction.
Name , y6
.. .tea ....... t. ... :....... ......I...........
�F/V�l\rGl' 111 N111.LL� YY•
5 73 permit for remodel & add
No .1..6.... ....................................
Um (2) bathrooms
9 �
Location .......................................... d......... . ..
.....................HYanni s.....,....................................
Owner .........Arthur W. Spencer
........................ ..............................
Type of Construction ...................frame........... s
Plot ............ ..... .. Lot ................................ '
a.
November 14 _ 72 -�---��--
Permit Granted ........................................19
Date of Inspection
Date Completed ... ...... 19 ._,
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PERMIT REFUSED
................................................................ 19
.................................................................. ...... � � 3
... ........................................................................
...............................................................................
•.................................•.............................• ..........
Approved ................................................ 19
...............................................................................
...............................................................................
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Engineering Dept. (3rd floor) Map � � � — Parcel 1 )1 /Permit#
House# -0-25 9,3 1---J_S Date Issued r
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee ,Gyp
Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00) ; SEPTIC SYSTEM MUST FEE dAA1vW-L
.—LED IN G®
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a t. 1st floor School Admin. Bldg.) �
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V!I'TH TI
Plan Approved b Planning Board 19 E ,7 7r 0
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BARNSTABLE.
MASS.
TOWN OF BARNSTABLE$�iilding Peit Application -V �- l
eet Address A00 . ai CO O S f-i2 of
Village A fU 0 l
Owner Q-�1 f) L I S .73'A V\1 L4 L q-r I Address O! iJ( 10
Telephone 00 _—,A
Permit Request N0 i0 Effo► T t-'i.5-1 kY W A. y t~ T I►y c, C.O ti G�/L 't 5�(J
Q eh 0U C S L 1 t0 r�� `�wS i ALc_ 1 L-0►00 0(.S a 0 tJ 0()LJ _1� 17-
O R - CJ t,., t,r5 �A� EE N�TI R,c- Fi20J-r'
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ DO
T
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type,and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes , ❑No If yes, site plan review#
Current Use Proposed Use
,,/n� Builder Information
Name tJ i d ifT Ca,If ro � Telephone Number c/ y
Address 0 �3 V License# Q (a 0 (y_S
F—U Cc S�44(-t Me, 001 0 4 H Home Improvement Contractor#
Worker's Compensation# (4) 0 (0 3 t{
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE OOJ DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
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