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HomeMy WebLinkAbout0070 LONGWOOD AVENUE - Health w �ti ? ,� M ,� =— =S7.OLongvV`0odrlve E' F Hyannis 287 091 , y a a b I� y ° e i ° O No.`�` v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes i3 PUBLIC HEALTH DIVISION = TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for Vsposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components XLocation Address or Lot No. too Owner's Name,Address,and Tel.No. X Ass?sssorsNl- ap arcew lb�� V !L , 4j2-W C/Z 1 - ` Installer's Name Address,and T 1.No. i� S'u ryi ma�rS' esigner's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd _ Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nwv�L- com�-G a� TD fia �c o�✓ .�-N�o z.�co NET Prier- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o�/.f lt�G�.t, c Si d Date Application Approved by Date 3/h 3 Application Disapproved by Date for the following reasons Permit No. a�� "'Jr� Date Issued c3 ✓ 3 4 { � x J 3 5Ge ; f _\ � �` Fee O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes f, 21ppYication for sposal 6pstetft Construction Vermit Application for a Permit to.Construct( )Y� Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components X .Location Address or Lot No. � �I�I� Owner's Name,Address,and Tel.No. X / -7 0 Lo nl6W_a 4V-q Assessor's Map/Parcel, Installer's Name 1 u 2 Address,and i No. s�rn rn�r�v a��nesigner's Name,Address,and Tel.No l� a �s P�'� / —SoC) 5 Type of Building: J� /l Dwelling No.of Bedrooms 1 " A- Lot Size sq.ft. Garbage Grinder( ) �l Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) P/ gpd Design flow provided gpd Plane., Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 01 S L 0 r4-"CST" P 1 p I£. .Fadwl k x I S TI W6 S1 FT 7 L M con-a G o nl TD f-p o Al 2 g-c o i c- Nature of Repairs or Alterations(Answer when applicable), • Date last inspected: I Agreement: j Y The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until.a Certificate of . r Compliance has been issued by this Board. the Sigh d Date Application Approved by Date APPli aiorf'Disapproved by Data for the following reasons t I Permit No. `� 3 — SL Date Issued 3 / 3 _,... - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(� ) Abandoned( )by i4/L ►k ��- 1 7� at Lo a Gw-&-e O H�Mw f41 S& s been constructed in accordance J with the provisions of Title 5 and the for Disposa? Aa4hLji §tem Co struction Permit Nod.L! '50 d hated tv >Installer) C � mac Designer #bedrooms Approved design flow Algpd The issuanc;�f s err�nit shall n t be tru as a guarantee that the system 'll -i de 'fined` _ Date J �%j Inspector / f ---------- ------------- ------- -------------------------------------------------------------------------------------------- No. �' 3 SG Fee /C) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal *pstrm Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) I System located at /d (.Q4G INZ W)0 kv✓ }-}y ww is 6--1—T I. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must Pe comoleted within three years of the date of this permit. permit. Date ��// Approved�b McKean, Thomas From: McKean, Thomas Sent: Friday, July 20, 2012 3:15 PM_ To: 'mark@boudreaulaw.net'; Crocker, Sharon Subject: RE: 70 Longwood Avenue/Updated -----Original message----- From: McKean, Thomas + Sent: Friday, July 20, 2012 3 :07 PM To: 'mark@boudreaulaw.net' Subject: 70 Longwood Avenue Hi Mark, This is to confirm that the septic system at the above referenced property has the capacity for seven bedrooms: This property is not located within any zones of contribution to public water supply wells or saltwater estuary zones and is therefore not limited in regards to number of bedrooms. Therefore, I have no objections to maintaining seven (7) bedrooms total at this property. Sincerely, Thomas McKean NOTE: Documentation: The Health Division Office is in possession of the following documents: floor plan (sketch) showing seven bedrooms existing, an affidavit indicating the property has had seven bedrooms since 1968, and an evaluation from Stephen Wilson P.E. indicating that the septic system has sufficient capacity for seven bedrooms. 1 AFFIDAVIT I, Marian R. Frick, of Westwood, Massachusetts, do hereby on oath declare and say as follows: 1. My family has owned real estate located at 70 Longwood Avenue in Hyannisport, Massachusetts since 1946 when my mother, Lucile H. King, formerly known as Lucile H. Shepard, purchased the property. She added an additional parcel of land in 1956. 2. 1 became the owner of the property in 1968 when I purchased it from my mother. 3. Since that date;the property has remained in my family and is now owned by the 70 Longwood Avenue Realty Trust. 4. Every Summer since 1946 I have resided in this property. Since that time, there have always been five (5) bedrooms in the main house. My mother built a two (2) bedroom cottage on the property in 1960. The cottage initially had three (3) bedrooms but two of them were combined, almost immediately, into one bedroom. 5. The cottage has always been served by a cesspool and the house is currently served by a septic system. 6. The Town has the house listed for five(5) bedrooms and the cottage for three (3) bedrooms. C Marian R. Frick COMMONWEALTH OF MASSACHUSETTS , Barnstable,ss: July 12, 2012 Then personally appeared the above named Marian R. Frick, an individual known to me, and acknowledged that the foregoing statements are true and accurate to the best of her knowledge and belief, before me My commission expires: 4�_ NOTARY PUBLIC MARK H BOUDREAU NOTARY PUBLIC _- Commonwealth of Massachusetts My Commission Expires May 2, 2014 c 4 7 e r 'V V MILDRED D. LINNELL & WILLIAM J. O'NEIL, JR. REAL ESTATE & INSURANCE HYANNIS PORT, MASS.02647 TELEPHONE 775-0709 �-, �- �� � �� �.5.. �� i.� �. . - „ ,. "' �\� i v �� �� .. r �,� �� - �� `� �� `-�° l �. �_� �` MILDRED D. LINNELL & WILLIAM J. O'NEIL, JR. REAL ESTATE & INSURANCE HYANNIS PORT,MASS.02647 TELEPHONE 775-0709 , C Baxter Nye Engineering and Surveying 79 NOrth Street,Hyannis,Massachusetts 02601 . July 16`h, 2012 Mt Thomas McKean Health Director r 200 Main Street Hyannis, Massachusetts 02601 Re: 70 Longwood Avenue, Hyannis Port Dear Mr. McKean, Attached lease find m calculations regarding' the ca"capacity of the existing septic system. The P Y P Y g calculations are based on the following items. • The "old" Title V (pre— 1995)was used to determine the septic system capacity. • The cesspool that was disconnected,from the cottage and is being reused as a leach pit has the same leaching capacity as the newer precast leach pit. Based on this the repaired septic system has the capacity to accommodate seven bedrooms. If you have any comments or questions.please call me at 508-771-7502; ext 13 or contact meat swilson@baxter-nye.com. Sincerely, S en A. Wilson,:P.E. cc: M. Ford- Esq: . kh4s13 #2012-031:01 C` ov3 sbi I i=li� sZ BOHLettendoc " a a : s01 4 bL,� ���� �,v: v,�c {-1 u a�,�► 5 3��r�r. 569�J 7�i za i 4r-wA en a.,c-ik-u ln¢se-AL ofcat 79: ce- t �v 4i G ►4 a c i cr I I o&,t s �I O C w�12 l 5,��T� � '� Ne I v�� wt v•� � Lc.�rJc G c�"�I t S ,S 6�� air �Gt��t '�c3ssl 1 SOQ gdtl�Y►s L-S 1,6Q© t,cl�oyl5 o�Gk • l do n ��,aQ- =- ' ( 1 C� ��� �� '�`�eta� � rca�e�n g �t�, cu,.s ivvc t�.... l Oor S S U wlt I O ✓t.G Gi.V`-G�.�.-�m� C�.Q C N 1/JS 3 d C Y1'1 YZ 1 5 t 3 Ck cLk,a.`i Gfi.pre�l�'4 �kk:/�C.W b�t � �� -A 1 ol `s. J A � �1[Z�PCf ra P.) IIO No. Fee —. C THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Applitatiou for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) ❑Complete System [s]Individual Components Location Address or Lot No. 17cs ,�, 1o� A� Ownerr'ss Name,Address,and Tel.No.(�/ - - Assessor's Map/Parcel ��— 4 ang163 �v VrAck- S3 9�y r ?! Installer's aj�e,Address,and Tel.No.3'p,8. C� fr. go2� Designer's Name,Address,and Tel.No. RV ' l Type of Buildin . Dwelling No.of Bedrooms Lot Size ICJ2� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 'A � 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 e a not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si - Date i Application Approved by Date Application Disapproved by Date for the following"reasons Permit No. 2 Date Issued Y -No.' ' Fee )d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Otsposal 6pstem Construction Permit J Application for a Permit to Construct( ) Repair 0 Upgrade( ) Abandon( ) ❑Complete System 'Individual Components Location Address or Lot No. !V �.�fl� jAVv Owner's Name,Address,and Tel.No.6/0- 173V- ,j30,�, Assessor's Map/Parcel �X/ ! 0 0) !� F, q (� 1 /" ;_�Qi-. �M 4 F"> - V � \1�"I ` ���.4��t 3 7-'�•���[' /t`1!! nd yr i 1e,1 r 1P ;A n�l.a_ � s z l,lln` Installer's ame,Address,and Tel,No.j U�, (���_ ��ta Designer's Name,Address,'and Tel.No. Type of Building: Dwelling No.of Bedrooms j� Lot Size ` 3� A<-&4,-/J sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank �. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (t�� �, O i �,,," �.i o •�,,� 4 s Date last inspected: i Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system-in accordance with the provisions off'itle 5 of the Environmental Cod aE d of to place the system in operation until a Certificate of Compliance has been.issued'by this Board of Health. _ Sign Date j T Application Approved by _ Date / Application Disapproved by't /� , Date " for the following reasons Permit No. 7 o (� �► Date Issued /11. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ; ^k� Certificate of Compliance (.T41rs IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by J ��r ( i, "k, w"I _i r at t)/) P.c i I Vleik,v,,'c n has been constructed in accordance with the provisions of Title 5 and the for Disposal Sys em Construction Permit No. :-2 di 1 dated 2- Installer f -lti�„ ��,LT„�4 JJ Designer #bedrooms Approved dig w l �i/�_ .gpd The issuance of this permit shall of be construed as a guarantee that the system wil nct'o as designed/ f "' Date . Inspector /(''�*!f(( ------ ------- No. _ ( � " J Fee /00 f' THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit,- Permission is hereby granted to Construct( ) Repair( dK Upgrade( ) Abandon( ) System located at '�)/3 f , � ,, r ,YZ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date /' J r Approved by QIJC4, I • . ti..w SHE � Town of Barnstable Barnstable °� Regulatory Services Department etcaCi BARNSTABLE•Q• ' public Health Division - T MASS. m . �ATFb MP't 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7011 0470 0001 4525 7277- June 26, 2012 John M. Cornish TRS 7 Journey's End Lane Lexington, MA 02421 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 70 Longwood Avenue, Hyannis, MA was last inspected on 6/12/2012, by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00). 0 Cottage must be tied into septic tank You are ordered to repair or replace the.septic system within two (2) years from the date you receive this notification. PER ORDER OF THE BOARD OF HEALTH - omas McKean, R.S. CHO Agent of the Board of Health , Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\TOB Itr Parcel Detail http:Hissgl2/intranet/propdata/Parcel Detail.aspx?ID=2 168 3 ` i;..,.i r r is !!�I•—' f as+hy.w.,.� . Logged In As: Parcel Detail Tuesday, June 26 2012 Parcel Lookup Parcel Info Developer Parcel ID 287-091 Lot Location 70 LONGWOOD AVENUE I Pri Frontage 110 Sec Road WASHINGTON AVENUE I Sec 150 Frontage village HYANNIS I Fire District HYANNIS Town sewer exists at this address No I Road Index 0920 Asbullt Septic Scan: -Interactivel, 287091_1 Mapj Owner Info Owner CORNISH, JOHN M TRS I Co-Owner 70 LONGWOOD AVE RLTY TRUST Streets 7 JOURNEY'S END LANE I Street2 � � City LEXINGTON - State MA zip 02421 Country Land Info Acres 0.38 I use Multi Hses MDL-01 I zoning RF-1 Nghbd 0117 Topography Level I Road Paved Utilities Septic,Gas,Public Water I Location Water View - Construction Info Building i of 2 Year 1890 I Roof Gable/Hip I Ext Wood Shingle I FUsiSaj Built Struct Wall BASI241 1,.• Living 3494 ( Roof Asph/F GIs/Cmp I AC None Area Cover Type R93. Bed AT Int . Style Colonial Wall Plastered I Rooms 5 Bedrooms 4 Model Residential I Floor Pine/Soft Wood I Rooms 4 Full+ 1 H I oK 14 0: Grade Luxury Minus I Heat Type Hot Air Rooms 9 Rooms A stories 2 Sty w/UAT I Heat Gas I Found- Cone. Block I Is 1 27 Fuel ation `B Gross 5287 Area Building 2 of 2 Year Roof Ext Built 1946 I Struct Gable/Hip I Wall Wood Shingle http://issgl2/intranet/propdatalParcelDetail.aspx?ID=21683 6/26/2012 Commonwealth of Massachusetts =T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 70 Longwood Ave Property Address George Frick Owner Owner's Name information is H annis Ort required for Y P MA 02647 June 12, 2012 every 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 A. General Information �/� forms on the "I computer,use 1. Inspector: only the tab key P to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name rQ 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 S1 12855 Telephone Number License Number c CD B. Certification ° r - °.` -03 I certify that I have personally inspected the sewage disposal system at this address andthat 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-f Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails VInector's ds Further Eval n by the Local Approving Authority June 12, 2012 Job# 12-93 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•11/10 Title 5 Official Inspection E.uuce Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 70 Longwood Ave - Property Address George Frick Owner Owner's Name information is Hyannisport MA 02647 June 12, 2012 required for State Zip Code Date of Inspection every page. City/Town 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: System Conditional) B S st Y Passes: Y ❑ 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 l5ins-11110 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments M 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for y p H annis ort MA 02647 June 12, 2012 every page. CitylT'own State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hy p annis ort MA 02647 June 12, 2012 every 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 El ® 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hy p arinis ort MA 02647 June 12, 2012 every 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. 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. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Longwood Ave Property Address George Frick Owner Owner's Name information is H annis ort re uired for Y P MA 02647 June 12, 2012 every page. Cityrrown 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 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 !Sins-11/10 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 w„ 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hy p annis ort MA 02647 June 12, 2012 every page. CitylTown 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied 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: l5ins-11110 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 70 Longwood Ave Property Address George Frick Owner Owner's Name information is H annis Ort required for Y P MA 02647 June 12, 2012 every page. City/Town 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: Unknown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..'" 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hyannisport MA 02647 June 12, 2012 every 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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' 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.): Septic Tank(locate on site plan): ' Depth below grade: 1 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 3" 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hy p annis ort MA 02647 June 12, 2012 every page. CityrFown 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 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" i Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Longwood Ave Property Address George Frick Owner Owners Name information is H annis ort required for Y p MA 02647 June 12, 2012 every page. Cityrrown 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 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? ❑ Yes ❑ No l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 70 Longwood Ave Property Address George Frick Owner Owner's Name . information is H annis ort required for Y P MA 02647 June 12, 2012 every 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 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-11110 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 70 Longwood Ave Property Address George Frick Owner Owners Name information is H annis ort required for y P MA 02647 June 12, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ 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.): Leaching pit#1 is an older block pit,waste lines from cottage are piped directly in. This pit is now technically a single cesspool causing a system failure by town standards. Leaching pit#2 had 20-24" of standing water and no high stains. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Longwood Ave Property Address George Frick Owner Owner's Name information is required for Hy p annis ort MA 02647 June 12, 2012 every 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-11/10 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 70 Longwood Ave Property Address ------ — -- ----- --- George Frick Owner - — ------------------...-----Owner's Name information is required for Hyannisport _MA 02647 June 12, 2012 every page. Cityrrown 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 / J f / r r f f / / / / \f\r\r\:�/\/♦/,/\/♦/\/,r I25 / I / 17 '\ ♦ \/\ \/\/\/\/ , 34 J / / JJJJ . / 27 \�,�,�,�,�,�, 44 '4 / , J „ / , / / „ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Longwood Ave Property Address George Frick Owner Owners Name information is required for Hyannisport MA 02647 June 12, 2012 every page. Cltylrown 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: 15+ 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: Beach and surface water at end of road is considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w. 70 Longwood Ave Property Address George Frick Owner Owners Name information is required for Hyannisport MA 02647 June 12, 2012 every page. Cityfrown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Card Page 1 of 1 TOWN OF BARNSTABLE LOCATION 70 y 7t) SEWAGE# VII.LAGE. � SESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. A d��Q SEPTIC TANK CAPACITY ..13?J4d_t4U�. LEACHING FACU=:(type) (size) NO.OF BEDROOMS 9QEb9fiR-6R OWNER PERMITDATE: COMPLIANCE DATE: 3a�y3� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (lf 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 P.S.to of I I OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPEGTION FORM - PART C SYSTEM INFORMATION(mmumed) eropenY Adaeev: A . j SEETCB OF SEWAGE DISPOSAL SYSTEM Provide a Aemb ofdx Haase dkp=d eyawm keludk{fimm a k.two p—mml eeRmaaa lendmarke m brmbmarlu Lave e0 we0a widtin 30 put Loved wbem peblk water apply mma the bwld4 . " I G _ o G'co http://www.town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=287091&seq=1 6/25/2012 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EIMRON-MENTAL PROTECTION n ra TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ��(� 0r Owner's Name: 0 A4 �a Owner's Address: e,' ' LoLi A-IA.QDY& Date of Inspection: _ Q. a ' Name of Inspecto � I\ s Company Nam Mailing Address: ,' ) Telephone Number: ' CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and.complete as of the time of 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 DE.P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: �/t15—'" The system inspector shall submi opy 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 � .,.. -� s s........ . .. .e e .`.r-. ..» VP... .r - R ti nr ..,, q ♦ .. r �.. '' ;.."M.'. k.. .a. ".!t♦y.. ****This report only describes conditions at the time of inspection and under the conditions of use at that ,V 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 l Page 2 of 11 .4 A,.... i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ ) Owner: ,GI ' Date o nspectio O JV Inspection Summary: Check A,B,C,:D or E./AL.WAYS complete all of Section D A. System Passes: !f I have not*found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.' Comments: B. System Conditionally Passes: One.or more system components as described in the"Conditional Pass section-need to be replaced or repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N ND)in the for the following statements. If"not determined"please explain. 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 th-, existing tank is replaced with 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: 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 obstruction is removed distribution.box is leveled or replaced ND explain: The system required pumping.mare than4 times a year due to broken or obstructed pipe(s).The system will pass inspection.if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 1 l OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r � , Property Address: / s Owner Date of4nspectio 0. (� 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 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 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 DAP 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 fonn. 3. Other: 3 Page 4 of 11 y I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: � � Owner: Date of nspecti e ,• Gzt D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes No/ _ ly, 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 j Liquid depth in cesspool is.less than 6"below invert or available volume is less than 'h 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. i✓ 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 pub]icwell. V Any portion of a cesspool c.r 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 r 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 t _ determine id system fails. I have deter i .,( ) y m n d that one or more of the above failure criteria.exist as described in 310 CMR 15303,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 _ — 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:. jr n"I Owner: Date of nspectio c7 Check if the followinghave been done. You must indicate` es"or"no" as to each of the following: `Y Yes No % Pumping information was-provided by the owner,occupant,or Board of Health t_ `" Were any of the system components pumped out in the previous two weeks? as the system received normal flows in the previous two week period ? Y Have large volumes of water been introduced to the s stem recently or as art of this inspection? _ Y P P _� Were as built plans of the system obtained and examined?(If they were not available note as N/A) .7 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 in_erior of the tank inspected for the condition q6theTiahes 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 owne-)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: Yes no V 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMJNFORMATION Property Address: Owner: Date of I spection: _ - / FLOW CONDITIONS RESIDENTIAL. V Number of bedrooms(design): 5 Number of bedrooms(actual):r� DESIGN flow based on 3 10 C R 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents:-& / Does residence have a garbage grinder.(yes or no).( Is laundry on a separate sewage systewit s or.no):�.[if yes separate inspection required] Laundry system inspected(ye or no): Seasonal use: (yes or no):ALZa. - Water meter readings, if av -able last 2 ears usage d $ rJ``C� QGf ' vim ® g , ( y � (bP ))��"� Sump pump(yes or no): �- Last date of occupancy: 27t a2'� COMM ERCIAL/INDUSTRIAL ItI6) Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft;etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):'_ Water meter readings, if available: Last date.of.occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: r(, � Was system pumped as part of the ins ection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: i AYE OF SYSTEM Septic tank, distribution box,soil absorption syste;n _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) _Tight tank _Attach a copy of the DEP approval —Other(describe): p�roximate age of all components,dal. installed(if known)and source of)',nformati n: r z M AL � Were sewage odors detected when arriving at the site(yes or no): b 6 f Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM q PART C SYSTEM.INFORMATION(cor_tinued) Property Address: y Owner:\J,14 Date of n`spectio BUILDING SEWER(locate on site plan) Depth below:grade: Materials of construction:_cast iron 40 PVC_other(explain): 'Dist:nce=from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: t (locate on site plan) Depth below grade:DX-L—Z& Material of construction: 'concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) ) / . Dimensions: /�v� �XC_e x Sludge depth: f/7 it Distance from top ofsludge to bottom of outlet tee or baffle: . Scum thickness: NO Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom .f outlet tee or baffle: How were dimensions determined: T. Comments.(on pumpingrecomme tions, • let and outlet tee or baffle condition,structural integrity, liquid.levels related to outlet invert,eviden e of leakage, etc.): GREASE TRAI (locate on site plan) Depth below grade: Material of construction: concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance.from bottom of scum to bottom of outlet tee or.baffle: Date'of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8.of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: �� ( ^ Vie. nk Owner: Date of Inspectio . )e&,Q,)C�6S TIGHT or HOLDING TANK:_/—Vatank 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes o:no): ' Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (/ if resent must be o ened locate on site plan) ( P P )( Depth of liquid level above outlet inve-t: L �� Comments(note if box is level and.distribution to out_ets�ual, any evidence of solids carryover, any evidence of 1 kage into or out of box, tc r , � 1 r J n t PUMP CHAMBER: (locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances; etc.): R i Page'9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . 1 SYSTEM INFORMATION(continued) Property Address: Owne tA - Date of Inspectior5. '" f ;.. SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: -. . leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool, number: _innovative/alternative system Type/name of technology: Comments(note condition of soil signs of hydraulic failure,level of pon.3ing, damp soil, condition of vegetation, etc.) fi. J qn�t / GiL�('i2�C/� •�" „ram ® CESSPOOLS: lrJ"jL(cesspool must be pumped as part of inspect ion)(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.grour.'dwater inflow(yes`or no):. Comments(note condition-of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: locate on site Ian ( P ) I. Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): A 9 Page 10 of 11 ° OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: Owner: j ate of I►(§pectio D ng Ae,(d C', 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 -00 feet.Locate where public water supply enters the building. CJ�, k O p � ► ID _ r CX� � �. Page I 1 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: Of Owner: Date of Inspection. ( � ��) � SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet . Please indicate(check)all methods used to determine the high ground water elevation:' Obtained from system design plans on record-If checked,date of design plan reviewed: 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: 11 F Permit Number: Date: R. s - Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Z9 L.-;P Lot No. Owner: /t. /-/� (� Address: Contractor: �r,?�o/O � Ct��95 Address: Jr �� �rs�`yY / Notes: �7/r�/��67y ,- ��`/5 STEP 1 Measure depth to water table to nearest 1/10 ft. ............................................................................ .Date month/day:/Year STEP 2 Using Water-Level Range,Zone and Index Well Map locate site and determine: (A Appropriate index well...................................'..`............., . OWater-level range zone .................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to J� water level for index well ..........................: month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) , determine water-level adjustment .......................................................................................... /. STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water �U� levelat site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 A. i. IkN 9 • t. ' i+ No.... -_ Cl_ FRs..-. 2..:. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnr#iun Errant �v pp�on ishefeby npde for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ystem at: f1l rites(� ..............1.C... .�^ ©y (.v0� -_..ox_z�................ ---- ................................... Location-Address or Lot No. Owner Address a 1/ 1 c�.s_------- ,� ................. ... �.k.3 ------..�� r ...........--- Installer Address d feet Type of Building Size Lot___________________________S q. V g _____Expansion Attic ( ) Garbage Grinder ( )Dwellin of Bedrooms____________ __________:_____________. '4 Other—T e 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 ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ �-7 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_-_____________________- P4 ------------------------------------------------------•----•-----•--------------•---•--•-•-•--------......................................................... 0 Description of Soil......................................................................................................................................................................... x V -------------------•-----------•----•---------•---.._..---------------------------....-•---------------•------•--•-----------------------------------------------------------------•._..._•------•----- W x ----------------------------------------•----------------------------------------------------------------------------------------------------------------•--------------•-----•----------------•------- U Nature of Repairs or Alterations—Answer when applicable.-__-_— -44----_____/-__-_,l"/�_______TO____.EX1 SFZ taao.....C---A-1;:-------�` n,1r---- °�r.................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e /issd bathe oard of health. Signed ---------- ------ - - -------- --------------------------- -........................... ..-s -'�. .� .. Date Application Approved By ---------- - . — - Q Application Disapproved for the ollowing reasons- ---------------------- -------- -------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- Date PermitNo- ------------------------------------------------------------- Issued .......................................................------------ Date No.... t?__...��A.. - _ - _1 - - Fps..... ..................... THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH _ TOWN OF BARNSTABLE Appliration for Disposal Works Tonstru.rtion Frrutit � /Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal f ystem at: k)�iJ�Z-1 �j Location Address or Lot No. i O.i. _._ Cl � ........'FX_/�!l�....................... _ owner - Address .•-•••-•• `ar (�� s.------........G................. �Pk 3.�f.....__._ .,7 .._...... ..... Installer� Address Q Type of Building Size Lot............................Sq. feet V Dwelling—471�o. of Bedrooms.......... _.___.. _____Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d ,✓ 'Other fixtures ------------------------------------------------•.....--- Design Flow:"tip.._._ ------------------------gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ 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--_-_._______-_;--_____. fi Test Pit No. 2................minutes per inch Depth of Test Pit-_-___-_-_.._.----•- Depth to ground water........................... P14 •---••••-•------------------•--•-••••-•-•-•••••--•••---••-•--•••-•--•-•...------•---••••....---••---........................................ __...I O Description of Soil...............................................................................=......................................................................... •............ /..................•-----•---------•-------•---...--•--------------•------------------.........--••---•-•---------------------------•--------•-......---•----------------------------•--•------`-------- W ----------------------------------------------------------------------•-•-----------------------•----------------------------•--•---------------•------------------•-------...••----------------------•- U Nature of Repairs or Alterations—Answer when applicable_.....�Q _._____.`....�41........TC1-•••.eF�X -�T� '4 .........vGd.-......`-! � ''�� .. �r...........--•-----•-----------------------------------•-•-....................................................... Agreement: The_undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions-of.TITLE 5 of the State Environmental Code The undersigned further agrees not to--place the - 'system in operation until a Certificate of Compliance has b e ss dpyi Ehe oard of health. e/?JSigned ......... .....................f...---.....---.........---------------------........--------------------------- -------------------------------------- . v , Date Application Approved By ------------- -------- ` v --- _-------------------------............................... ..... ...-. ..-.. 0.... Date � Application Disapproved for the following reasons- .......................................................-----------_................................................................... ----------------------------------- -- ------------------ ----------- ------------------------------------------------------------------------------- ---------------------------------------- Date ...............................................Permit No. --.-------...---...---------------...........---....----- Issued ....................................................--------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cgertifirate of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by -------------------V.. ............ Installer �1 -------------------... .. .. ..............................----------.............................. at ............... ----- - has been installed in accordance with the provisions of TITLE of he State Environmental Code as described in the application for Disposal Works Construction Permit No. ------- ....... ----- dated ...................� .........__......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS`A GUARANTEE/THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ATE....... Inspector ................. ........1 THE COMMONWEALTH OF MASSACHUSETTS, BOARD OF HEALTH TOWN OF BARNSTABLE - No......•�..•..-L.�.!Q FEE.....3© Disposal Works Cons#rud� ion rrntit Permission is hereby granted it ld •-••••---•-•••--•-••-••••••--•-••-••..............••••••••..............-- to Construct or $epair (>0 an Individual Sewage Disposal System . at No.............� ._......... .. r o /. ............ ^ Street UU as shown on the application for Disposal Works Construction Permit No.:_�Q"'l_' _ Dated.......................................... ............................... ...cM------------------•--•-.---------------•-----•---•--•- _ _ .. Board of Health --------------------------------------------------------- DATE.......... �_...__...---•--•--------------••----------.... FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS TOWN OF BARNSTABLE LOCATION D vv O®J 4 v e SEWAGE# 2-® � VILLAGE /j-r�-f �O/ ASSESSOR'S,MAP&PARCEL aD INSTALLER'S NAME&PHONE NO. �� ✓� C/C7//� t/.. ��-y? `f 3a SEPTIC TANK CAPACITY I�a LEACHING FACILITY.(type) ,p i 4� (size) / 000 a NO.OF BEDROOMS/ OWNER S!n ri VCR/ PERMIT DATE: /����//� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY zdo � eve C 1 Il f O p � 1 0 TOWN OF/BARNSTABLE 'LOCATION tQ SEWAGE# VILLAGE -10=—ASSESSOR'S MAP&P�Ae RCEL INSTALLER'S NAME&PHONE NO. 1 �, r C°od�� i"7 1-� SEPTIC TANK CAPACITY C—I LEACHING FACILITY.(type) r�— NO.OF BEDROOMS S OWNER �ZiGIL PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ���� < ._1 a� � a Z r � r � J ;_;• — TOWN OF BARNSTABLE 'LOCATION 70 0 NC-i000X 44Lk— SEWAGE # VII,LAGE� UB�liyt,to A SESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY. 15 2 —a,;, LEACHING FACILITY: (type) (size) NO:OF BEDROOMS OWNER PERMITDATE: COMPLIANCE DATE: Rl-'olay Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by „ Page 10 of]1 f OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY:ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of 13pectioa (�(��•e � 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:00 feet.Locate where public water supply enters the building. l 1 it \ L�C - t t. 1 I I PL4N,B0Q'K 832 PAGE 88 LONGwoop ; (8D WIDE PU8LIC)4VENUE CONCRETE CURB Q JT4D�E MAI _ _ +d •�.80FIBD8 AS � 1N3W3AVd!0 3003 OE 1 _ HEOOES 29.2e• 6 e BI PORCH - �� I r ^ fC ESSA J I j I H I c III - __ '• e .' A T QI - PID ° - 1 (MAI 38 O1J PtijftlMgflN�IN1Y13N 313enHDD mf� V to It I I I -C.-.�,.: ..�.-.:'- _.-' --r._.��•......-. -..: ._ ...- � -.... I Ti'�'y\. -, __ ..'„��„ .��r' � m.->5ir H r 7=--�.31-.,a`-s _ _.. _.._- c -i�f r ' Y B 0B;.u4 I - MAP 287/PARCEL 82 i I - CHRISTOPHER NSF p - -R• do MARCELLA D. HEAD L.C. PLAN No. 20173 PLAN REFERENCE IN HA Riggs Im R SIR 5p s� q M m 1 ' il Q / vg II ! Eat I PROJECT TITLE .:.... - v O In _ m `�v- m D C1 D _ 2 2 - ,� O O _ fn� -1 5 00 aA V/ m W e i m o m mmi 70 Longwood Avenue � > y a � .. \�v 6 I m n¢ Z . c c - i�' T ^ gg QR YJ Hyanris POfI,MA.,02847 Z i c z vvTT I a� m Z ur ; o ` s�y{y SRY.�� yµ�� q��y�tpy g�yw�N tz' I AM 1 I] UPOIiE 116R01418B5 TO pYEllQx dU L!R,i'6 7S E .. NO a DATE DESCRIPTION Bv�m