Loading...
HomeMy WebLinkAbout0180 LINCOLN ROAD - Health 180 LINCOLN RD. HYANNIS A= 270 050 .00 i i 'Sep 04, 2019 10:12 HP Fax page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form ki Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name r information is required for every Hyannis MA 02601 8-29-19 page. City/Town Ys State 21p Cade Date of Inspectlon Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. `,`, u+u nf►upirl, F Important:When A(11� `Sd'G�� filling out forms A. Inspector Information '''' '•�� �.� 0?; ycy on the computer, _ :' JAMES N= use only the tab James D.Sears key to move your Name of Inspector 1 .0 use cursor Bono _Capewide Enterprises key. Company Name >+�F •... `��.� 153 Commercial Street �yy'��nrli n npt ``����\ BSI Company Address Mashpee MA _ 02649 CitylTown State Zip Cod® 508-477-8877 S1623 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 8-30-19 Spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. tSInsp.doc•rev.712812018 Title 5 official Inspection Form;Subsurface Sewage Disposal System-Page 1 of 1s Sep 04, 2019 10:13 HP Fax page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form 54 Subsurface Sewage Disposal System Form •Not for Voluntary Assessments t�,T, 180 Lincoln Road Propery Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspectlon C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which Indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal, Tank D Box and four chamber's. 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): Mnsp.doc re'+.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Sep 04, 2019 10:13 HP Fax page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced. ❑ Y ❑ N ❑ NO(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): I 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.tloc rev.7/2612 0 1 8 Title 5Oficisl Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 -- F Sep 04, 2019 10:14 HP Fax page 22 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29.19 page. Cltyffown 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 ooliform 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.7126/2016 Title 5 Official Irepedon Form:Subsurface Sewage Disposal System•Pepe 4 of 18 ' Sep 04, 2019 10:14 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in eismspsoHs less than 6" below invert or available volume is less than Ya dayflow AEAC# C ❑ ® 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. Cl ® 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 collform 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 ❑ Cl 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.M612018 Tille 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 18 Sep 04 2019 10:14 HP Fax page 24 c Commonwealth of Massachusetts TV Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question In Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate regional office of the Department, 6. You must indicate"yes"or"no"for each of the following for af!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. ❑ ® 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.712612018 Title 5 Offldel Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Sep 04 2019 10:15 HP Fax page 25 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 180 Lincoln Road Property Address --- Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 1500 Gal. Tank D Box four chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2017-50,100Ga1s g ( y g (gPd))' 2018-70,400Ga!s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5lnsp.dac•rev,7126/2018 Title 5 Offlael Inspection Form,Subsurface Sewage Disposal System-Page7 of 18 Sep 04 2019 10:15 HP Fax page 26 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments 10, 180 Lincoln Road property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommercialRndustrlal 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc rev.T126/2018 Title 5 Olfkiel Inspection Form:Subsurface Sewage Disposal System•Paae 8 of 18 Sep 04 2019 10:15 HP Fax page 27 Commonwealth of MaSSachuSettS Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name Information is Hyannis MA 02601 8-29.19 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. ❑ Other(describe): Approximate age of.all components,date installed (if known)and source of Information: " 1999 Permit # 99-301. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 37" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH -40. t5lnsp.doc•rev.7/26/2018 Tl6e 5 Official Inspection Form.Subsurface Sewepe Disposal system•Page 9 of 1 e Sep 04 2019 10:16 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner owners Name information is required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Code Dale of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-TapeSludge 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.): Tank at working level. Tank and outlet cover at 27"below grade w(inlet cover at 1. In and outlet Tee. No sign of leakage or over loading. t5inap.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Dlsposal System-Page 10 d 16 Sep 04 2019 10:16 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IRV, 180 Lincoln Road `J Property Address Richard Favor _ Owner Owner's Name information is Hyannis MA 02601 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.): B. Tight or Holding Tank(lank 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: galleons per day 151nsp.doc-rev.7125 018 Title 5 Official Inspectlan Form:Subsurface Sewage Disposal System Page 11 of 18 ' Sep 04 2019 10:16 HP Fax page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 180 Lincoln Road Properly Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 — Page. CltyfTown State Tip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: --- --_ - -- -- Date Comments (condition of alarm and float switches,etc.): Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-34" below grade. Box is clean and solid w/one Ilne out. No sign of over loading or solid carry over. t5insp.doc•rev.7/26(2016 Title 5 Orfldel Inspection Form:Subsurface Sewage Disposal System•Page 12 or 18 Sep 04 2019 10:16 HP Fax page 31 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 180 Lincoln Road u� Property Address Richard Favor Owner Owner's Name information is required for every Hyannis MA 02601 8-29-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No~ Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): ' If pumps or alarms are not in working order,system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Wnsp,dm rev.7/2012018 Me 5 011dal Inspection Form:subsurface sewage Disposal SpLem Page 13 of 18 Sep 04 2019 10:16 HP Fax page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form tSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Lincoln Road Vz. Property Address Richard Favor Owner Owner's Name Information is required for every Hyannis MA 02601 8-29-19 require page. CitylTown State Zip Code Date of Inspection D. System Information (cont,) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators.Ck D Box- Prob area and camera out line. No sign of over loading or solid carry over. No sign of holding water. 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.): tbinsp.doc•rev.W28/2018 TJW 5 MOW Inspection Form:Subsurface Sewage Disposal System-Peas 14 of 18 Sep 04 2019 10:16 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information 16 Hyannis MA 02601 8-29-19 required for every _ _. CNITown page. State Zip Code Date of Inspection D. System Information (cant.) 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.): Mnsp.aoc•rev.7)2612018 TWe 5 Of lal Inspectw Form:Subswfaoa Sewage DIG Wal System•Page 15 of to ' Sep 04 2019 10:16 HP Fax page 34 Commonwealth of Massachusetts Title 5 official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor owner Owner's Name information Is required for every Hyannis MA 02601 8-29-19 page. Gty/7own 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 l O t r7r 13-3 .y - % t5insp.doc•rev.712W2018 Tille 5 cfBcial Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Sep 04 2019 10:17 HP Fax page 35 c Commonwealth of Massachusetts Title 5 official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name equir at(fo is every required fo Hyannis MA 02601 B-29-19 r page. C(ty/Town State Zip Code Date of Inspection D. System Information (cont.) 16. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 264 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: Gis Map. You must describe how you established the high ground water elevation: G.W. at 26.+. Bottom of Leaching. Bottom of chamber's at 4' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doo-rev.728/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ' Sep 04 2019 10:17 HP Fax page 36 Commonwealth of Massachusetts U1 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 180 Lincoln Road Property Address Richard Favor Owner Owner's Name information's required for every Hyannis MA 02601 8-29-19 page. City/Town State Zip Coce 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 Summery: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist).completed ® D. System Information: For 8: TightlHolding 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 0124 b E l6v/7im 13� wo Wnsp.tloc•rev.71M018 Title S Official Inspectlon Form:Subsurface Sewage Disposal System•Page 18 of 18 c Date:Z/ TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ��a S z" c BUSINESS LOCATION/P110 INVENTORY MAILING ADDRESS: �G r,24e)��/�'�/ �'p�., �.�,//� TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: va r EMERGENCY CONTACT TELEPHONE NUMBER: 2 MSDS ON SITE? TYPE OF BUSINESS: GL_rvi/ ,,, INFORMATION/RECOMMENDATI NS: 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) t Photochemicals (Fixers) Gasoline, Jet fuel,Aviation gas 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) y Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) Any other products with "poison" labels ❑ NEW ❑ USED (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 &stairi removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Sign ture Staff's Initials TOWN OF BARNSTABLE p LOCATION < �� �, �«� - SEWAGE * VILLAGE /�s}�l1./�/7l� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. C'��� / SEPTIC TANK CAPACITY 0 G41, LEACHING FACILITY: (type)1" 1 4 (size) /d X30 .C2 NO.OF BEDROOMS 3 BUILDER O OWNE PERMITDATE: Z 7 7 COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ _-�, r . . \^r V . ® : � � o ���1 .. r � � ". 4 : y y • J 8 �" �'' I No. �— � D � Fee_1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,MASSACHUSETTS Zipprication for loigpool Opgtem Congtruction Permit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) /complete System 0 Individual Components Location Address or Lot No. /6a )�Co/ l'y , Owner's Name,Address and Tel No Cd Assessor's Map/Parcel ll a�le p� �0�rGri'Pw JJ Installer's Name,Address,and Teel..No. / Designer's Name,Address and Tel.No. 9 Type of Building: ^^�� Dwelling No.of Bedrooms ) Lot Size sq. ft. Garbage Grinder(-,(-P Other Type of Building /t e._51 A CC No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /r�a gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title L Size of Septic Tank ��' D Type of S.A.S. t � � Description of Soil to��JDX Nature of Repairs or Alterations(Answer when applicable) /I Ge Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is oar fJiealth.. Signed �� Date Application Approved by Date IL.Y�4 Application Disapproved for the following reasons Permit No. "3® / Date Issued No: Fee ;v, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ...•��'-�:... .- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes E lipplication for Mi!5poq;ar *potem Construction Permit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) CM Complete System ❑Individual Components Location Address or Lot No. `��� / )yf Owner's Name,Address and Tel No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,3o�'�oLorfi CO��sy; Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(�) Other Type of Building P_/( S/GP�i�I�No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �l� gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5,W Type of S.A.S. y /5%r 64 Description of Soil Nature of Repairs or Alterations(Answer when applicable) I / Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a-Certifi- cate of Compliance has been issued by is Boar of ealth. Signed �� � Date - Application Approved by �.,..,_ Date S--•�' •�/ Application Disapproved for the following reasons pt� Permit No. q ..3 O ( r!lit Date Issued ------------------------ THE / COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the Ort,-site Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( )by ,tfof to&4LI efew 1, at �Q G Aff CD n An," has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this e t shall,/no/t�.be construed as a guarantee that the sy'�s-Rwwill funccttiion as designed. {� (' Date Ll I Inspector /44�/ l 1 _ � — � �---------------- No. ----2 —v.SD Fee E) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1Xh6po.5al *pgtem Construction Permit Permission is hereby granted to Construct( ) pair( Upgrade( )Abandon( ) System located at �� G/ne,�, Z, d � i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: -`�_.t I -�q Approved by L S y V 5 "t D� TOWN OF BARNSTABLE LOCATION �� G� �� ! SEWAGE # VII.LAGE •�YQ'r�r�l� ASSESSOR'S MAP & LOT ZOO—D.SrtJ INSTALLER'S NAME&PHONE NO. BB!'14�9i�011`f 4�011U;7- SEPTIC TANK CAPACITY O 4W LEACHING FACILrrY: (type) 4 ,! 74Y (size) /0 e3U .C2 NO.OF BEDROOMS 3 . BUILDER O OWNE ``c .r- PERMrrDATE: S " Z-1 7 9 COMPLIANCE DATE: " l Separation Distance Between.the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a,Yy� 1/6/99 Y NOTICE: This Form Is'To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERNUT (WITHOUT DESIGNED PLANS) 4© 0-'- hereby certify that the application for disposal works construction permit signed by me dated /ISQ� concerning the property located at �® lo�fdC'O�j� /� ����s meets all of the following criteria: /The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /There are no wetlands within 100 feet of the proposed septic system /There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] /If the S.A.S. will be located with 250 feet of.anY vegetated etated wetlands the bottom of the proposed P P leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 2O +.the MAX.High G.W. Adjustment DIFFERENCE BETWEEN A and B ' SIGNED : DATE: i [Sketch proposed plan of system on back]. q:health folds:cent