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0023 MARK'S PATH - Health
23 MARK'S PATH,HYANNIS A= 271094.009 I f, r Town of Barnstable Barnstable ftv Regulatory Services Department j o BARNSPABM "`79. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 4070 October 18, 2017 ELLIS, DENISE K ESTATE OF 8200 JONES BRANCH DRIVE MCLEAN, VA 22102-3110 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 23 Marks Path,Hyannis,MA was inspected on 10/12/2017 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet (per Town Code 360-9.1). Pits holes and walls are covered with sludge; also showed solid carry-over on top of inlet line. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE ARD OF HEALTH s c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\23 Marks Path Hyannis.doc �tKE r� Town of Barnstable Barnstable Regulatory Services Department a WUWcaCd„ � BARNSTAgL& Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 4070 October 18 2017 ELLIS, DENISE K ESTATE OF 8200 JONES BRANCH DRIVE MCLEAN, VA 22102-3110 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 23 Marks Path, Hyannis, MA was inspected on 10/12/2017 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or _ sspool with high liquid level, <12" below inlet (per Town Code360-9.1). �� �O&S pus are C-4+'-'ed W,),• 51vd�p ' -tisa %I,a� Su (�A o yer on 4-op OP t n�I- A Iv " O`> You are ordered to repair or replace tfie septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\23 Marks Path Hyannis.doc Town of Barnstable ,�xxtist•R*�, Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Sc4 Director FAX: 508-790-6304 'Thomas A McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground Y . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe: ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). . 4qm Pees AR Dspoo ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) aching pit or cesspool with high liquid level,<12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: a\SEPTICOEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentsµs 23 Marks Path Property Address Freddie Mac ¢0 Owner Owner's Name information is ✓ MA 02601 10-12-i ��' �D required for every Hyannis page. CitylTown State Zip Code Date of Inspection :�l 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 A. General Information filling out forms /. 143{ ```yNq+�rirrrin,p„� on the computer, ` ```a����tN QF Mq 6,,���' use only the tab 1. Inspector: sycy,15 key to move your a` cursor•donot James D.Sears _ �: JAMES sz use the return ^ SEARS = Name of Inspector a v: ;r„ �sy. Capewide Enterprises g*�• '; Company Name 153 Commercial Street " �nunun+�•�� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CHAR 15.000).The system: ❑ Passes ❑ Conditionally Passes Fails- ❑ Needs Further Evaluation by the Local Approving Authority 10-14-17 ;pZoMsslg�nature 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 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. Sns.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 )mzdvs a5ed xed dH 1,&OZ L 02 9 6 130 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page, City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E I 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: Failed -Leaching. The system is a 1000 Gal, Tank D Box and pit. B) System Condltlonally 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): I5ins.dw•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 11 Z a5ed xed dH I,E:0Z L L02 9 6 100 c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. Cityfro wn State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): l ❑ 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.doc•rev.6H6 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System.Pape 3 of 17 , £ a5ed xed dH 1•£:0Z L 60Z 91. 1-30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 ff/45 OEEN ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool g,4 S 6£FAo' ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in is less than 6" below invert or available volume is less than day flow AT 1-4 A 5 6 E f-N t5ins.doc•rev.6116 Title 5 Dfrolel Inspection form:Subsurface SErmage Disposal System-Page 4 of 17 b abed xed dH 1•E:0Z L 60Z 91, 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cost.) 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 groundwater 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 colifomt bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 6 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 falls.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.doc•rev.6116 Tltle 5Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of tl g a5ed xed dH 6£:0Z L 60Z 91, 1)0 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is Hyannis MA 02601 10-12-14 required for 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? ® El Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6116 Title 5 Official Inspection Form:subsurface Saaage Disposal System•Page 6 of 17 9 a5ed xeJ dH E6:02 L1,02 96 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information Hyannis MA 02601 10-12-14 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and Pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015-17,400Gals g ( y g (gPd))' 2016-32,000GaI s Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 150s.tloc-rev.6116 Title 5 OMdal Inspectior Form:Subsurface Sewage Disposal System-Page 7 of 17 L abed xeJ dH 2£:02 LME 96 100 Commonwealth of Massachusetts mom: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 23 Marks Path Property Address Freddie Mac Owner Owner's Name Information is required for every Hyannis MA 02601 10-12-14 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type Y 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.doc-rev.6116 Title 5 Official Inspector.Form:Subsurface Sewage Oisposel System-Page 6 of 17 9 abed xed dH MOZ L 1.02 9I,. 100 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owners Name information is required for every Hyannis MA 02601 10-12-14 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1985 Permit S 85-152 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34"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. Septic Tank(locate on site plan): Depth below grade: 2 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: 1000 Gal. Precast H-10 Sludge depth: 3" t5ins.doc-rev.Er16 Tile 50rfidal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 6 a5ed xed dH ££:OZ L I.OZ 91, 100 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information Is required for every Hyannis MA 02601 10-12-14 page. Cdy/Tcwn 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 27" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level. Tank and cover's at 2' below grade. Inlet tee,outlet baffle.Tank shows signs of being full to cover. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from to of f p scum to op o outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date. t5ins.doc•rev.G116 T tie 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 10 of 17 0 6 abed xed dH ££:OZ L 60Z 91, 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 23 Marks Path Property Address Freddie Mac Owner Owner's Name Information Is required for every Hyannis MA 02601 10-12-14 e 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 t5ins.doc rev.6116 Title 5 Of el Inspection form:Subsurface Sewage Disposal System•Pape tt of f 7 I,6 abed xed dH VE:02 L 1.02 91, PO Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. Cityrrown 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.); D Box is 16"x16"-32"below grade w/one line out Wall's are oone on box Need to replace Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located,explain why: Oins.doc•rev.1118 Title 5 Official Inspection form:Subsurfece Sewage Disposed System•Page 12 of 17 z l, abed xeJ dH b£:OZ L 1,0E 91. 130 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owners Name information is required for every Hyannis MA 02601 10-12-14 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ 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 is a 4' precast pit w/3'stone. Pit and cover at 31" below grade. Pit wall's and holes are covered w/sludge. Solid carry over on top of inlet line Need to replace leaching i 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 15ins.doe-rev.6/I6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 0117 £6 abed x2J dH t7£:OZ L 1.0Z 9 6 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. Cityfrown 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 vegetati)n, etc.): i t5ins.wc-rev.wi 6 Title s omciai Inspection Forrn:Substdace Sewage Disposal Systern Page 14 of 17 t 6 abed xed dH VE:0Z L60Z 96 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately DATA L e� -� - 317 t3 -�- 36 13 -�-= 39 -3 A `3 r WV 3 � b 8- 3 49 "3 y t5ins.doc-rev.6116 Title 5 Official kmpection forth:Subsurface Sewage Disposal System-Page 15 of 17 5l, abed xed dH b£:OZ L1.0Z 96 130 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Marks Path Property Address Freddie Mac Owner Owner's Name Information is required for every Hyannis MA 02601 10-12-14 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N D Estimated depth t high ground watery 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10-18-84 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: T.H.on Design plan 10-18-84 12' no G.W.. Bottom of pit at 6'-6" below grade. Bottom of pit at 51- 6"above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. i5ina.dtx•rev.6118 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 9 1, a5ed YU dH 5£:OZ L ME 91. 100 e Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 23 Marks Path Property Address Freddie Mac Owner Owner's Name information is required for every Hyannis MA 02601 10-12-14 page. C4f7own 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.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Olsposal System Page 17 of 17 L I, a6ed xed dH 9E:02 L 1.0Z 91, 1:)0 C3 •. • N 0 C3 OFFICIAL US E Q' Certified Mail Fee Cr Extra Services&Fees(check-box,add f2a-sappdr-qpfiatq) LHgy—e� Return Receipt(hardoopy)rq $aReturn Receipt(electronic) $ 1 V1 0 ❑Certified Mail Restricted Delivery $❑Adult Signature Requ ired $OAdult Signature Restricted Delivery$O Postagem $ � Total Postage and Fee I $ ! ELLIS, DENISE K ESTATE OF ul Sent To rq { 8200 JONES BRANCH DRIVE StieetandApt No.,oi� MCLEAN,VA 22102-3110 Ciry,State,20+40 ( t :r� r rr rrr•r, — -- Certified Mail service provides the following benefits: e A receipt(this portion of the Certified Mail label). 4 for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate is Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. a USPS®-postmarked Certified Mail receipt to the ■A record of delivery(Including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. —j Important Reminders: Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which •Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the in To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a ) certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion'_ of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. Ps Form 3800,Apdi 2o15(Reverse)PSN 7530-02-000.9047 e Complete items 1,2,and 3. A. Signature ® Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee Attach this card to the back of the mailpiece, B. eive�l by(Printed Name) C. D e of D livery ® or on the front if space permits. �� 1. i" D. Is delivery address different from item 1? ❑Yes j If YES,enter delivery address below: ❑No ELKS,DENISE K ESTATE OF 8200 JONES BRANCH DRIVE 11YCLEAN, VA 22102-3110 3. Service Type ❑Priority Mail Express@ it l�lll�l Iall �I I II II I I I III�II��II(I'I I III ❑Adult Signature ❑Registered MailTR Adult Signature Restricted Delivery ❑Registered Mail Restricted Certified Mail® �� ppeliv.ery 9590 9402 1933 6123 1799 31 Certified Mail Restricted Delivery m+Retum Receipt for ❑Collect on Delivery J�//"'Merchandise �0 A.+:.•i__wi_.��.—..r - - - - - •—•---- -�'-^-"—`-�Delivery Restricted Delivery ❑Signature Confirmation 7 015 . 17 3. 01. 4 9 9 0..4070 _ ; . eI ❑Signature Confirmation it Restricted Delivery Restricted Delivery (over$500) PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACKING# First-Class Mail I Postage&Fees Paid USPS Permit No.G-10 9590 9402 1'91 6 23 1799 31 I United States F Sender:Please print your narn:e,address,and ZIP+4®in this box* Postal Service Town of Barnstable Health Division 200 Main Street Hyannis,MA 02601 I I � I 3.. :=i•t::s.:�?�s�� „I�iiliti'♦:t3t���'II'1'llll�lllll }11�1"II�IiI�'tiiltll'�"�'il li , o Complete items'1.,2,and 3. A. Signature f ile Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee B. R ceived by(Ponted Name) C. Date of Delivery 8 Attach this card to the bask of the'mailpiece, i or on the front if space permits ,711& IS �1 I<«' 1.;Article_Addressed-tn,____ D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address belowi p No I� Federal Home Loan Mortgage Corp. • 82001ones:Branch Drive-, McLean, VA 22102-3110 t _ II �III�I III I�I I III I II�I I I I I III I II��I I II I I 3. AduServiceti Type ❑Registered t ered Mail less® ❑Adult Signature O Registered MaiIT^' ❑Adult Signature Restricted Delivery-. ❑Registered Mail Restricted 9590 9402 2480 6306 7772 99 ❑Certified MaiIO Delivery + ❑Certified Mail Restricted Delivery ❑Return Receipt for i El Collect on Delivery Merchandise I—Collect on Delivery Restricted Delivery O_Signature ConfirmationT"' � 7-015 `'17 3 0�0 0 01 4 9 9 0 ,2 7 8 6 Insured Mail ❑Signature Confirmation nsured,Mail Restricted Delivery Restricted Delivery (over$500) , PS Form.3811,July 2015 PSN 7530-02-006-9053 (� Domestic Return Receipt .=I USPVTgACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 I 9590 9402 2480 6306 7772 99 I jUnited.States •SenderPlease print your name,address,ar'd ZIP+4®in this box* Postal Service I °4 Town of Barnstable Health Division I 200 Main Street Hyannis,MA 02601 A �_ { � t i l r 4 s br �fHE T Town of Barnstable sn[cxarea[.a, MAS& Regulatory Re ulator Services i679• ,0�' prfD MA'�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 12, 2017 Federal Home Loan Mortgage Corp. 8200 Jones Branch Drive McLean,VA 22102-3110 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS. The property owned by you located at 23 Mark's Path Hyannis, MA was visited on May 8, 2017 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted in response to a complaint filed with the Public Health Division. The following violations of the Town of Barnstable/Board of Health Regulations, Chapter 54 Building and Premises Maintenance were observed: 04-3 (A) Outdoor Storage Multiple items are being stored outdoors on this property which are not screened from public view and are not within an enclosed structure as required by above ordinance. These items include but are not limited to: car parts, trash, garbage, broken lawn mowers, furniture and other assorted debris. You are directed to correct the violations listed above within (15) days of your receipt of this letter by removing said items from property or storing them in.an enclosed structure You may request a hearing before the Board of Health if written petition,requesting same is received within 10 (10) days after the date the order is served Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the in ction. P R ORDER OF THE OARD OF HEALTH omas A. McKean, R.S. Director of Public Health Town of Barnstable 'itizen Web Request Page 1 of 2 7s � � logged In As: Citizen Request Management Thursday,April 132017 TOWN\Oconnelt Route to Users Search Requests Create Requests i Request Information Request ID: 58711 Created: 4/12/2017 8:29:30 AM Status: Assigned To Staff Assigned.To: O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 4/26/2017 Change Estimated Mar April 2017 Dmay Completion Completion Date: Date: 128 Wed Thu Fri Sat 29 30 31 1 5 6 7 8 12 13 14 15 19 20 21 22 26 27 28 29 3 4 5 6 Created By: Sousa,Vanessa Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request Map: 271 Block: 094 ;Lot: 009 I "It appears abandoned. Number _.......... . The major window is smashed and others are Parcel Lookup boarded up and the front lawn is strewn with belongings.The fence is collapsing and no occupants have been seen for some time." Email: ripis@yahoo.com Edit Requestor Information Track Request Progress � h Request Work History: Internal Note History: =^�V http://issgl2/intemalwrs/WRequest.aspx?ID=58711 4/13/2017 V -r `M!-FIealth Master Detail Page 1 of 1 Logged In As: TOWN\oconnelt Health Master Detail Wednesday,April 19 2017 Application Center Parcel Lookup Selection Items. i Parcel Septic Perc Well Fuel Tank Parcel: 271-094-009 Location: 23 MARK'S PATH, Hyannis Owner: ELLIS, DENISE K ESTATE OF � I_ Business name: I Business phone: Rental property: ❑ Deed restricted: ❑ Number of bedrooms : 0' Contaminant released: ❑ Fuel storage tank permit: ❑ I Save Parcel Changes ! Return to Lookup Parcel Info Parcel ID: 271-094-009 Developer lot:LOT 9 Location:23 MARK'S PATH Primary frontage:. Secondary road: Secondary frontage: Village:Hyannis Fire district:HYANNIS Town sewer exists at this address:No Road index:2042 Asbuilt Septic Scan: 271094009 1 Interactive map: may., Town zone of contribution: SPLIT (parcel is split between districts and Should be looked Up on the map) State zone of contribution:IN Owner Info owner: ELLIS, DENISE K ESTATE OF Co-owner:%FEDERAL HOME LOAN MORTGAGE CORP Streetl:8200 )ONES BRANCH DRIVE Streetz: City:MCLEAN state:VA zip: 22102-3110 Country: Deed date: 12/1/2014 Deed reference:28540/286 Land Info Acres: 0.30 use: Single Fam MDL-01 zoning:RB Neighborhood: 0104 Topography: Road: Utilities: Location: Construction Info lBuilding N ear Buil Gross ArealLiving Are Bedrooms lBathrooms 1 11985 K442 11820 3 Bedroom 3 Full-0 Half Buildings value:$148,700.00 Extra features: $39,000.00 Land value: $69,400.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=271094009 4/19/2017 k0C-ATION .. a3 SEWAGE PERMIT NO. VILLAGE A I N S T A LLER'S NAME i ADDRESS i;� _ H le<" R U I L D E R OR OWNER DATE PERMIT ISSUED. DAT E COMPLIANCE ISSUED �Z4_ - e e �f n n J No...��..J Fxs...... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------------.....OF....1.6 C'- ................................... Appliration for Kliiivviial Works Tonutrurtion ramit JApplication is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal ystem at: .............. ....... .......... - ---------------------..........--- Location-Address or Lot No. ......................—.......................................................................... ..........--...................................................................................... W � ,, �-��Owner --- -------Address Installer Address Type of Building Size Lot../ ......Sq. feet U Dwelling—No. of Bedrooms......... .............................. Attic ( ) Garbage Grinder (A/O) aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( ) 0.' Other fixtures .----••-------- --------------- - --- ----------------------------------------------•••------------ W Design Flow............. .......................gallons per person per day. Total daily flow.......... .....................gallons. WSeptic Tank—Liquid capacity>?�?o...gallons Length_,'_A"__. Width¢.2©_`_`_ Diameter________________ Depth_: `4."- x Disposal Trench—No_ ____________________ Width.................... Total Length.............._..... Total leaching area____________________sq. ft. Seepage Pit No........I----------- Diameter____!Z`________ Depth below Total leaching area_A�............sq, ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed _________ Date.__ _ -- ~__�� Test Pit No. 1..... ........minutes per inch Depth of Test Pit..... _ `_____ Depth to ground water.._ _ OF.iy (s, Test Pit No. 2........._......minutes per inch Depth of Test Pit.................... Depth to ground water_. O ROGER y� 9 �------- PAIn O Description of Soil- - f`. ., ®,c ��"— o''..... rae ......................................... 8.� MJCHN EWiCZ -------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-•• V Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------- ___________ --------•--------------------------•------------•----------•------------------------.....---....--------••---------------------------------------------------••--- Agreement: l The tin agrees to install the aforedescribed Individual Sewage Disposal System i accordance wit the rovision f i?'"� 5 of the State Sanitary Code—The undeIlt' rt:er agree of to place the system in ope ation i Certificate of Compliance has b issued by the boh. Date Application Approved By..... = � !G'= ----- 1 ... Da e Application Disapproved for the following reasons--------------------------------------------------------------------------------•----------•••-•-•-------------- .......................................--•-----•----•--•-•••...-••--•-•----------•------...-••-•----------••-••••-••-•••••••••---•••---•••-•--q ------•--------•----••----------•------------ ---Date--- Permit No....- �� -------------------- Issued -•T Date No.. Fes$.....� ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N 722Lea:--V-e...................OF.... ! -hJ�,,� .r ................................... ApplirFalinn for Disposal Works Tonstrurtinn Frrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at ••---•-----••• .............•--•-......_••••••--- Location-Address or Lot No. Owner Address W Installer Address UType of Building Size Lot._' _Zc'__ `9__.___Sq. feet �-1 Dwelling—No. of Bedrooms.........?______________________________Expansion Attic ( ) Garbage Grinder (No) aOther —Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------•-••---•••••-•••------•-----•-••--••-••--•-•--•- W Design Flow____ ____. ________________________gallons per person per day. Total daily flow_________�-' ___.________________gallons. WSeptic Tank—Liquid capacityA"�a_.gallons Length_I9.`_'_'___ Widths f�°_"__ Diameter________________ Depth_"_ .�r. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area____________________sq. ft. Seepage Pit No--------I----------- Diameter----A?�°:_.-_____ Depth below inlet._ c '___ Total leaching area_�_15/......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by- �.A ____!��! �__ •-��!�-4•._______ Date---/4?_-/A'�'� Test Pit No. 1....-�Z_s........minutes per inch Depth of Test Pit------e A'0_____ Depth to ground water..N OF Lt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___ .__ ROGER G Ri ------------------------------•-------------------------------------------------...---------._..........----•------••-••--•--••-- Description of Soil_42" " 45;?t !_.,'_,w!sSo� .-_-2 "� �Gy ..................................---- MICHNIEWICZ .....i"�.......................... ea N es: Frf ------•----•---------------------------------------•----------•---------•-•-•--••-•-----•-•------••-----------•-•------------------•-•-•-----------•---------------•----------- -- - i ail• ` U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________ ___________ 1 N� ....................................-.................................................................................................................................. ••-- Agreement: 1 / The undersigned agrees to install gn the e afor edescrlbed Ind>vidual Sewage Disposal System in ccordance with the provisions of TTT?;". 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sied...................................................................................... ................................ Dat�Application Approved By-•..-••-• s=� : ................................................... t: Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ ..----•--------------------------------------•--••---•- ----------------------------------------------------------------- C Permit No......00.5...=L __�________________ Issued......-_- - _ �2-_- _- -_._ �Date -. ----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................................................ Turrtifiratr of f ompliFanrr THIS IS TO CERTIFY, That the Individu l Sewage Disposal §ysteip constructed ) or Repaired ( ) Instal has been insta led in accordance with the provisions of rl T_ ; r: j of The State Sanitary Code s described in the application for Disposal Works Construction Permit No._7� -------=--_________ dated------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANT E THAT THE SYSTEM WILL FU CT14 SATISFACTORY. DATE........... ..................................... Inspector THE.ICOMMONWEALTH OF MASSA USETTS BOARDOF_.OF.------.............._...........--------------...._.-..._...----------------HEALTH �33,.� ��� ................. No. -=- -� FEE .................... Disposal Morkii Tn sir ' gmit Permission is hereby granted----= 5�- •- --= =-- ------------------ ------- ,_, to Construct (,)<) or Repair ( ) an India ual eve>age Disposal System at No.........-.z'•f:: `T r.. ` --••- --- Street as shown on the application for Disposal Works Construction Permit _ o._4�_-_— '-- Dated...... r--- � ................. .......... --.f�_'-'" ---`--------------------------------------_-• DATE.__..---...3---7=--1-----95 -•-••••----•-•-•-••--•--•-----• Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS RECEIVED p , yq TROY WILLIAMS 3 0 2001 SEPTIC INSPECTIONS JUL 1 OFBARNABLE ST Certified by MA Department of Environmental Protection (508) 585-1300 19 Hummel Drive South Dennis, VA 02660 COMMONWEALTH OF MASSACHUSE M'S / EXECUTIVE, OFFICE OF ENVIRONMENTAL,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION, TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ProperIN Address: 23 MaWs Path Hyannis,MA Owner's Name: William Donovan Owner's Addres,. 23 Mark's Path Hyannis,MA 02601 O Date of Inspection: July 25,2001 V O Name of Inspector: TroyM. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information g P y 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. 1 am a DEP appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The SN'stem V/ Passes Conditional),- Panes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/,2 /o i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. 1 his 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 race I Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 23 Mark's Path Property Address: Hyannis,MA Owner: William Donovan Date of Inspection: July 25,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that anv of the failure criteria described in 310 CN4R 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 n d to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by th oard of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following stat ents. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic to - (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank fail a is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approv by the Board of Health. *A metal septic tank will pass inspection if it is structurally s nd,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availabl . ND explain: Observation of sewage backup or bre out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settle or uneven distribution box. System will pass inspection if(with approval of Board of Health): , oken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syste quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection' with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Iaspection: July 25, 2001 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. L System will pass.unless Board of Health determines in accordance with 310 CMR 15.30 6)(b)that the system is not functioning in a manner which will protect public health,safety and th nvironment: Cesspool or privy is within 50 feet of a surface water r" Cesspool or privy is within 50 feet of a bordering vegetated wetland or a saltimarsh r 2. System will fail unless the Board of Health(and Public Wa r Supplier,if any)determines that the system is functioning in a manner that protects the public h th,safety and environment: _ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a surface \+ater supply or tributary to a surface wate upply. — The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. _ The system has a septic to - and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"" ethod used to determine distance "This system passes ' the.well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volaf organic compounds indicates that the well is free from pollution from that facility and the presence o monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 23 Mark's Path Property Address: Hyannis,MA William Donovan Owner: July 25, 2001 Date of Inspection: 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 clo2�2ed SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow 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. ya Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. &h Any portion of a cesspool or privy is within a Zone 1 of a public well. Nii Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4 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 %cater 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. /Vu (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with design now of 10,000 gpd to 15,000 gPd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the c ' eria above) yes no the system is within 400 feet of a surface drin g water supply _ the system is within 200 feet of a tribu to a surface drinking water supply the system is located in a nitrogen nsitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water suppl ell If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered "yes"in Section D above the lar system has failed.The owner or operator of any large system considered a significant threat under Secti E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner ould contact the appropriate regional office of the Department. 4 Page•5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Inspection: July 25, 2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the followine: Y No 7 _ I'..;:,pine information was provided by the owner, occupant, or Board of I Ical,l, 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 ? fHave 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) v/ _ 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: Yes no _ 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)J 5 Page-6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 Marles Path Hyannis,MA Owner: William Donovan Date of inspection: July 25,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): a 4 h- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33o Number of current residents: A Does residence have a garbage grinder(yes or no): Ato Is laundn on a separate sewage system (yes o: no):'�ro- [if yes separate inspection required] Laundry system inspected(yes of no):A,q Seasonal use:(yes or no): mo Water meter readings,if available(last 2 yearslusage(gpd)): ou t2 Ato„ T_r,_, �y /?� av v ju Sump pump(yes or no): No Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1 ;Title5 gpd Basis of design flow(seats/persons/5 Grease trap present(yes or no):_ Industrial waste holding tank prese _ Non-sanitary waste discharged to thm s or no):Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: NO Q art, ;pe 1 ! ri_ Was system pumped as part of the inscC n(yes o no): o If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: Tv7E 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) _Tight tank _Attach a copy of the DEP approval _Other(describe):. �.proximate age of all components. date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page-7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Inspection: July 25,2001 BUILDING SEWER(locate on site plan) Depth belu�ti grade: 18'' + Materials of construction: _cast iron Z40 PVC_other(explain): Dittancr from private water supply well or suction line: kip Comments(on condition of joints,venting, evidence of leakage,^etc.): t t�✓S a-r�_�,k.a.S o.:..t �^J — 4- "I h 1 •n.f•�- r . SEPTIC TANK: ;(locate on site plan) Depth below grade: f / 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_5'-11 _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 9 Flow were dimensions determined: I9iw6e. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, levidence l of leakage, etc.): c t 'f'„e ,rrr11�.t.e.•1t d_.„ --V!tYY�-✓`-4�_A_.a'`.".._ .i�y N••�--{ l�Cr Ca s/.n. - ---- w:�r�_;,,.t c?✓tJ s.i. �C7 .0 ',r r:/�<.. e. r ��.r- -t. :.a:� il.s:-.,••�•.... s a. .n/o. —��h.:j u.n V�. w d+� r h n.< ..d :� rC ✓,+� v, y c..+ -- GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete_metal_fiberglass olyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom of outle ee or baffle: Date of last pumping: Comments(on pumping recommendations i let and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of I age,etc.): 7 Page 8ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Inspection: July 25, 2001 TIGHT or HOLDING TANK: (tank must be pumped at time of ins chon)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions -- Capacity: gallons Design Flu\+ gallons/day Alarm present(yes or no): Alarm level: Alarm in working orde yes or no): Date of last pumping: Comments(condition of alarm and flo witches, etc.): DISTRIBUTION BOX: t✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): 4-7 J w 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 ps and appurtenances,etc.): 8 Page-9 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Inspection: July 25, 2001 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: X L< 4---t. P• •1 1..� 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.): K V W.i it > era `( e.�.� wdo�.�e ww ��. �e.�< (. � .ems: cJlt ,� �' �iCvo✓ f; 1 • (via >.-, y�/0 07 ta.) �+ '�.. r .�'' v�+ti✓•� �'p�..:..� ci.'f' /�ic .fj�M-< 4/e2 .L.��c'-✓7'0+1 CESSPOOLS: ((cesspool must be pumped as rrt of inspection)(loc eon site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum la.\er. _ Dimensions of cesspool Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of raulic 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 hydrau ' failure, level of ponding,condition of vegetation,etc.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 23 Mark's Path Property Address: Hyannis,MA William Donovan Owner: July 25, 2001 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. 1(ocat cwh re public water supply enters the building12 ) l i I � i t?� r lU f Page�l of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Mark's Path Hyannis,MA Owner: William Donovan Date of Inspection: July 25,2001 SITE EXAM Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water 7f' feet Adjusted high ground water elevation r feet Please indicate(check)all methods used to determine the high ground eater 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: lam) Y 1-„s , 912 Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: ,4/a+z 3;. z You must describe how you established the high ground water elevation: J� — S C J 4- �O�aA=i1. - /ZC ! / 6. L, 1. ��L 4"'F l�d.N S�J�i�✓` 7 -A dl CC—a a'� �- �". /"`^- •7)✓�,... ...�' :h 5 .S�• ./ -�o Il Il' ��19 BORTOLOTTI CONSTRUCTION,INC. 4 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-711-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address.. S V�/) Date of Inspection: Inspeetor's Name: o4, Owner's Name and Address: CERTIFICATION STATEMENT: I certify,,that I have personally inspected the sewage disposal system at this address and that the informs- tion reported below is true,,accurate and complete as of the time of inspection.The inspection was'per- formed based on my training.and experience in the-proper function and maintenance of on-site sewage disposal tems. The System: Passes Conditionally Passes Needs Further Evaluation By the ocal Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit'a copy of this inspection report to the Approving authority within thir- ty(30)days.of completing this inspection: If the system is a shared system otlas 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and-the approving authority. INSPECTION SUMMARY# A)SYS M PASSES: I have not found any information which indicates that the stem sy violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exftltration,.or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or,breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM`IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. v to stem and is within 50 Feet of a n a, � The system has a septic tank and soil absorptionsy P .. water supply 1 well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for colifornt* bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. ?The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 'day flow. r than 4 times in the last ear NOT due to clogged or obstructed Required pumping more y �l P P g pipe(s). Number of times pumped -2- f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I,of a public well. Any portion of a cesspool or privy is within 50 Feet of»a privaie 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance:withthe groundwater treatment program requirements of 314 CvIR 5.00 and 6.00. Please consult the local; regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has, been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. r The facility or dwelling was inspected for signs of sewage back-up. /The system does not receive non-sanitary or industrial waste flow. T--&:::�I'h- a site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on site. _L/The septic tank manholes were uncovered,opened,and the interior of the septic tank'was m spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. l-"The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) t/ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS REM—NTL4, Design Flow: allons umber of Bedrooms: c2 Number of Current Residents: Garbage Grinder: •✓✓QXr•(k aundry Connected To System:__)/z!?S Seasonal Use: Water Meter Readings,ifavailable: Last Date of Occupancy:( 1-126� COMMVRCIAL/INDUSTRIAL* Type of Establishment: Design Flow:' gallons/day -Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informat' n:�' �oL �.�,Li/h System Pumped as part of inspection:_ If yes,volume pumped: gallons Reason for pumping: TYPEPF SYSTEM: _Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APPROXIMATE AGE of all co ponents,date installed(if known)and source of information: Sewage odors detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: t/ Depth below grade: cP_ Material of Construction: concrete metal . FRP Other (explain) — Dimisions:$,S'Y� Sludge Depth: cP,/ Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffler" Distance from bottom of scum to bottom of outlet tee or baffle: ti'e`1 r; Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.)-7-';�S Ct_/Ddd� .fix 1 , GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth,of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete—metal—FRP Other(explain) Dimensions: Capacity: gallons Design Flow: aallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,,etc.) _. f DISTRIBUTION BOX: ✓ Depth of liquid level above outlet invert:`,�204" e& Comments: (note if level and distribution is a ual,evid ce8fi of solids carryover,evidence of leakage or o of box,etc.) r� ��QZ hi PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_Aj,:�' (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type. -Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure level of ponding,conditio of vegeta ' n� etc.)--t1 - O CESSPOOLS: A40 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) r -6- I } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. qq qq DEPTH TO GROUNDWATER: Depth to groundwater: 1 Feet Method of Determination or Appr ximatio f /�i�'�f�� t� T"!�/�I '5' •14� r -7- Town lof Barnstable- P# 5�S Department of.Regulatory Services / Public Health Division Date ��' 200 Main Street,Hyannis MA 02601 Date Scheduled <' Time—� Fee Pd. p° PCV a4� Soil Suitability Assessment for Sowage Disposal Performed By: ���'�°`� Witnessed Y,OCATTIyri&GEI�IERAU'1lNNFORMATI�DN Location Address Owner's Name a13 dark�er r� 1Cq1 CL rc_ Address wiv,.zlr6 jqt�, S, p L Assessor'sMap/Parcel: I /.Q ylo6q- / Engineer'sName Ser C-vi ihe�r�vt NEW CONSTRUCTION REPAIR 7 v Telephone# Ro'a j"L W lc3 Land Use 12,13�t�ri 4c— Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well 04 V ft Drainage Way ft Property Line ft Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 00 Al 4 L a Parent material(geologic) Depth to Bedrock �Q Depth to Groundwater: Standing Water in Hole: T L/( Weeping from Pit Face Estimated Seasonal High Groundwater l e DETEitMiATION FOZ�SEASQNAL HIGH WATER'TABLE Method Used: Depth Observed standing-in obs.hole: in. Depth to soil mottles: 3 Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ ! Observation ` PERCOI;A`TION TEST Date :� f /?F Ike:t'(. D Hole# Time at 9" Depth of Perc SZ Time at 6" Start Pre-soak Time @ 6'� Time(9"-6'1 End Presoak i Rate M-Anch y Site,Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. '+ Q:\SEPTIC\PERCFORM.DOC i 'DEEP OBSEItVATION-ROLE LOG` Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistenev.%Gravel) fc� t 1 IyEEP dBSER'�A3T01 SOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistenev.%Gravel)- lt'!� Low pm ( ors rig A (o AA sd'S,Nn 2_�y � "DEEP;OB5ERYATION HOLE LOG Hole'# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) `'DE��p OBSE�VA"�^I01�1`�HOLE LOG Hole# Depth from Soil Horizon - Soil T=1t= Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. Consistency %Gravel) ti l k t i 4 Flood Insurance Rate Mab: Above 500 year flood boundary Nc_ Yes V Within 500 year boundary No Yes 1 r Within 100 year flood boundary No Yes Depth of Natur.ally'Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? )e If not,what is the depth of.naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro ental P tection and that the a analysis was performed by me consistent with the required training, p and ex erience d in 310 C1VI1Z 15.017. yr� _Z I� .. Signature Date. f` Q:\SEPTIC\PERCFORM.DOC tl I t _ No. 30 l ' — 0( Fee U d .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pptication for lfgpooaf *pgtem Com6tructfon 3permit Application for a Permit to Construct( )Repair(' )Upgrade O Abandon( ) El Complete System 0 Individual Components Location Address or Lot No. a3 Owner's Name,Address and Tel.No. a Q(�'fl Ed nqar- Ferr2 ira) `I�a�3 �u rn�0 St �,, Assessor's Map/Parcel 1 0 U 001 ,1A 0 i A Pt 1 a/� + LJ L a�„M o f 4'r 1 i9 a to-7i—i Installer's Name,Address,and Tel.No. `l+ 1 �n BCD/� Designer's Name,Address and Tel.No. 313 +b Micro 2Oc� 2eQ�-� I�e6n1 M. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �e 2 + n 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Cal ulated daily flow s gallons. Plan Date )A I II—T D I) y Number of sheets Revision Date 1 Title Size of Septic Tank t Type of S.A.S. O Qj Description of Soil I Nature of Repairs or Alterations(Answer when ap licable) [' + C— o ' I fJ'—b0' I. (f �6 Date last inspected: Agreement: The undersigned agrees*o ensure the construction and mainten ce of e a described o - sewage disposal system in accordance with the provisions of Title 5 of the Environmental de t t lace the syst operation until a Certifi- cate of Compliance has been issued by is Bo ,4 Health. Signed { `'Date 111le 1,2942' Application Approved by 14 - Date Application Disapproved for th following reasons Permit No. U Date Issued ! lk No. �2 C) O y tiE Fee V .� t J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: f Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mtopozar 6poteut Con!5truction Permit Application for a Permit to Construct( )Repair(: )Upgrade(�)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a� Owner's Name,Address and Tel.No. q Ed rno r-- Ferreira 1 a 3 00 nip St Assessor's Map/Parcel al l JO� y 0 ri V A Pt 1,9 1 � (t�. 0rmoLj+1 069 to - Installer's Name,Address,and Tel.No. >��m COS G �S Designer's Name,Address and Tel.No. 313 +b P_urr) QOCV- lzCQ&_,9. -eveyicc /0. 5U8 -3 1-�S- 5 M (I S-V 9 7 9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building pQ5 i A 0 Cd rn No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date /.�Z 114 1 Q u 1) Number of sheets � Revision Date 1 4 Title Size of Septic Tank Ap <i ( I Type of S.A.S. -SVO fl lP Description of Soil I 4 Q r Nature of Repairs or Alterations(Answer when applicable) L Stoll i Ikov ��- \ 500 4a 110 II Jam, LJ,-i Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten ce of e a re des ribed on- • sewage disposal system in accordance with the provisions of Title 5 of the Environmental de of t 9 lace the syst in operation until a Certifi- cate of Compliance has been issued by this Board of / Signed Ix• l - ,.°mate & c /� Application Approved by r� Date Application Disapproved for thY following reasons + v Permit No. D o / DO Date Issued E /7// THE COMMONWEALTH OF MASSACHUSETTS Be - BARNSTABLE, MASSACHUSETTS rcotlFd dPr�yv, /o��' 330 Gpp itertificate of (Compliance / THIS IS TO CERTIFY,that the On-site Sewage Dilsposal System Constructed( )Repaired( )Upgraded V) Abandoned( )by C `�T o c+Cat S ,o�- at o6 M.0 rKS V Ql nvn t ) has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit.No. 20!( 00F dated r / 7 t J' r�"�Installer n 0 D A—a C+X—S, Designer 7 Ct'n e C �7 The issuance of this pe t shall :of be construed as a guarantee that the sy ten will �ctio\\ �d�e�sig�n<d�. ���� Date Inspector f No.—��------------ Fee (UU— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0'i,5pboal *pe;tem (Con!0ruction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( ) M System located at a3 M 0.rtCS 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. n� Provided:Construction must be completed within three years of the date of thi ermit. G` Date: I /�X ApprovedY b � i� �+ Town of Barnstable J oF % Regulatory Services Thomas F. Geiler,Director MAS& ` Public Health Division 39. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: g Sewage Permit# d0 -ONIAssessor's Map/Parcel 271/94 Installer& Designer Certification Form Designer: Sweetser Engineering Installer: PKM Contractors Inc. Address: P.O. Box 713 Address: 313 Hokum Rock Road South Dennis, MA 02660 Dennis. MA 02638 On /I/ PKM Contractors Inc. was issued a permit to install a 1(dat (installer) Path septic system at 23 Mark'sW Hyannis based on a design drawn by (address) Terence M. Hayes, RS . dated January 10, 2018 (designer) X I certify,that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic syste re renced above was installed with major changes (i.e. greater than 10' lateral reloc ion o the SAS or any vertical relocation of any component of the c s stem) but in ccorda ce with State & Local Regulations. Plan revision or certifi d a bui t esign to foll w. Stripout (if require ) s inspected and the soils ere o satisfacto OF Aji NII MII (Insta s a e H AYE 3 �! N01 , 979 T. (Designer's Si re) (Affix Designer's"Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form.doc SPAT It , N��,v�►s-"'►� � ST c�1� BAT n�AM �� ti now f3G �oo� c to SST TOWN OF BARNSTABLE .1 SEWAGE # 2 7 IIi.: AGE ASSES R'S MAP & OV`79009� 9 1 5 NAME&PHONE N( SEPTIC TANK CAPACITY 1066 QL1, sP L_FACHING FACILITY: (type) / (size) loQtI �G/s _ NO.OF BE7RO;WNER7: �& _ BUILDER �G PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ,l � � 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 fe t of le c 'ng facili /V/ Feet Furnished by �<` / ll®(.fit�✓l. �C Q�-t y� ���� � � � � -� � � . �� � - � r �, � � * F y � _ to t I� i y4 (C? l Qt - f J�-t-4y)2A1 i LJ rQ N kJ1, v :� COMMONWEALTH OF MASSACHUS ETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 2� ..OT TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS1111)SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 11 CD PART A CERTIFICATION - PropertyAddress: -- t t:o� Owner's Name; Owner's.Address: Date of inspection: Name of Inspecton (please pti_�t� !i✓• /'o�f��� Com pany Name: t— v Mailing Address; O 0 N 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 approved system inspector pursuant to Section. 1.5.340 of Title 5(310 CH T It 15.000• h stems. I am a IIEP 1 ___e system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 7 L�—& Date: The system inspector shall submit a copy of this inspection report to the A D P)within 30 days of completin this ins pproving Authority(Board of Health or g pection if the system is a shared system or has a design flow of 10,000 DE or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the uth The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of ins pectionof u at that time.This inspection does not address how the system will perform indthe futureunder u der�tions the same or different conditions of use, z Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART RT A CERTIFICATI ON(continued) Property Add 3 Address: Owner: 6 Date of Inspection: o Inspection Summary: Check A,D,C,D or E/AL_YS complete all of Section D A. Syste asses: I have not found any information which indicates that any of the failure criteria described 15.303 or in 310 CMR 15.3 . _w._nbed in 3 04 exist 10 C Any failure criteria not evaluated are _MR indicated below. Comments: B. Sy tem Conditionally Passes; C1_n_e Qr nl components Qre system_coonents 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 detern»ned(y,N,ND-)in the for the fQllowin explain. -g statements.if"not determined please The septic tank is metal_and over 20 years old*Or unsound,exhibits substantial infiltration or exfiltration orthtank septic ailure is imminent System will is strttch:_ally exiyrting tank is replaced with a complying septic tank as approved by the Board of Health. �s inspection if the *A metal septic tank will pass inspection if it is structural! y sound,indicating that the tank is less than 20 years old is available, not leaking and a Certificate of Compliance ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or-du e to a broken,settled or uneven distribution bo approval of Board of Health); x. System will pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla t: The system required pumping more than 4 times a year due to broken or obstructed ies. Th Pass i.tl&pecti_Qn if(with approval of the Board of Health); pp ( ) e system will broken pipe(s)are replaced obstruction is removed ND explain; Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: o i��Gly a b O Wnel; Co Bate of Inspection- o p C. Further Evaluation is Required by the Board of Health: SConditions exist which require further evaluation by the Board of Heal is failing to protect public ltealth,safety or the environment. th in order to determine if the system L System Will pass unless Board of Health determines in accordance with 31Q system is"fuuctio,ning in a-manner which will CT•Iit t5.303(1)(b)that th_e pxetect public health,safety-a$d the env'�renmeet: — Cesspool or privy is within 50 feet of a surface water Cesspool ar 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)a nd the SASS i�within 100 feet of a surface water supply or tributary to a Face water supply. — The system has aseptic tank and SA_S and the SASS is within a Zone 1 of a panic 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 tvel!**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the wen is free from pollution from that facili the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ty and failure criteria are triggered. A copy of the analysis must be attached to this form ,Provided that no other 3. Other: �� r Page 4 of 11 oFFICIAI,INSPECTION FORM—NOT SUBSURFACE SEWAGE DISPOSAL,FOR SYSTEM INSPECT N FOMENTS PART A FORM CERTIFICATION(continued) Property Address: �cgY/�� Owner- r J Bate of Ins q c petition: 1), System Failure Criteria applicable to all 4ystems; You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ t kup of sewage into facility or system component due to werloaded or clogged SAS or cesspool _ Discharge or Ponding of effluent to the surface of the ground or surfa_ waters du to 1 Clogged SAS or cesspool a an overloaded or !/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool rgmd depth in cesspool is less than 6"below invert or available volume is less than '/z day flow RAl— Le<luired pumping more than 4 times in the last year NQT due to clogged of times pumped aged or obstructed pipe(s). Number Portion of the SAS,cesspool ar privy is below high ground water elevation. Any Portion of cesspoot or privy is within 100 feet of a surface water supply. water supply ar tributary to a surface / U Any portion of a cesspool or privy is within a Zane I Qf a public well, —(� Any Portion of a cesspool or privy is within 50 feet of a Any portion of a cesspool private water supply well. 1� or privy is less thin 10q feet but treater th n 50 feet from a Rtivate water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, Performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that en other failure criteria are triggered.A copy of the analysis must be attached to this form,l Avffes/No)The system fails.I have determined that one or described in 310 CMR 15.303,therefore the system fails.The Of system ownve er�sho criteria ontact 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 mu gpd. st serve a facility with a design flow of 19,t10Q gpd to 1 S,Qgq You must indicate either"yes"or"no"to each of the following;(The folio ' g criteria apply to large systems in addition to the criteria above) s no the system is within 400 feet of a surface drinking water supply � the system is within 2QQ feet of a tributary to a surface drinkkngg ware[supply -- the sY is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA r pane i1 of a public water supply well )o a gipped If you have answered"yes"to an "yes"in Section Q above the large System has fstion in fai_led,The owner or operator of anction E the system is considered a significant threat,or answered significant threat under Section E or failed under Section II shall usystem y ge system considcrcd a 15.304. The systetn_owner should contact the appropriate regional a�e Qftths s m in accordance with 310 CMR 6. 4 . Department, r Page 5 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:tOwner. ct oDate of inspection: 0 0 Check if the following have been done.You must indicate"Yes"or"no"as to each of the followin : Yes o Pumping information was Prov ided ded by the owner,occupant, or Board of Health Were any of the system components pumped out in the previous two N,cek —� the system rece1Ved normal flows.in the preevious two week period Have large volumes of water been introduced to the system recently / tly 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) v Was the facility or dwelling inspected spected 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' nSPccof the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge a pro of the scum condition Was the facility owner(and occupants maintenance of subsurface sew if different from owner)provided with information on the proper age disposal systems ve The size and location of the Soil Absorption System(SAS)on the site has been determined based on: no Existing information. For example,a plan at the Board of Health Deternuned 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)] 0 ��� Pgage 6 of 1 I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address. a� l��J �t7 sne1 Owvner: r Date of inspection: q RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): .� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of Number of current residents: ( bedrooms): Does residence have a garbage grinder(yes or no): //40 Is laundry on a separate sewage system(yes or no): Laundry system inspected(yes or no): [if yes separate inspection required) �o Seasonal use:(yes or no): /Y.O Water meter readings,if available past 2 years usage(gpd)): Surnp pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design now(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): Pumping Records. GENERAL INFORMATION Source of information: ak 12 y 0 W►'yiv- Was system pumped as part of the inspection(yes or no):LYq Pimping: If yes,volume pumped: nallons—How was quantity Reason for Q y pumped determined? TyP! YSTEM (tic 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 obtained from system owner) (to be ---Tim tank Attach a copy of the DEP approval Other(describe): Approximate age of all g components,date installe (i wn)and source f information: o Were sewage odors detected when arriving at the site(yes or no): Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYS PART C TEM INFORMATION(continued) G rJtf Owner. c�oo.c Date of Inspection. o 0 BUELDING SEWER pocate on site plan) l/ Depth below grade; / Materials of constriction::c iron O PVC Distance from private waterlY well or suction liner(explain): Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK;_✓(Iopte on site plan) Depth below grade:_ Z f�// Material of constriction: concrete_.metal—fiberglass_polyethylene If tank is metal list age:_ Is age confirmed certificate) by a Certificate of Compliance(yes or no): (attach a copy of Sludge depth X -- Distance from top of sl Scum thickness: eio bottom of outlet tee or baffle: .3/ // Distance from top of to top of outlet tee or baffle: Distance from bottom of scum to bolt of outlet tee or baffle: How were dimensions determined: fro/e ,(�� Comments(on pumping recommendations,inlet and tlet as related to outlet invert,evide of 1 tee or baffle condition, structural inte eaka t tc. liquid�, ! Y> q�ud levels o O e c� J / g H e 'M Cs✓� T-�`f f ry rTG q 4/ Oro GREASE TRAP.L(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_berglass(explain): —polyethylene_other Dimensions: Scum thickness. Distance firm top o— f scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffl—e_Date of last pumping Comments on ( pimping recommendations inlet and outlet tee or baffle condition, as related to outlet invert,evidence of leakage,etc.); structural irate Vty, liquid levels page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: CO �4tY k"f /9w CtKd• Owner: !C o.►c(.. Date of.Inspection: TIGHT or HOLDING TANK: must be pump at time of inspection)(locate on site plan) Depth below grade: Material of construction concrete metal fiberglass 1 _po yethylene othea(explain): Dimensions: Cast: Design Flow: t;alIons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm andd float switches,etc.): DISTRIBUTION BOX: �presentmust be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' or out of box, tc,); 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.): Page 9 of I OFFICIAL.INSPECTION FORM_ NOT FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ASSESSMENTS PART C 'I'ION FORM ? SYSTEM INFORMATION(continued) Property Address: J Owner: L o a c Date of Inspection 0 oy SOII,ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why: Type eaching puts,number: (y w leaching chambers,number: reaching galleries,number. eaching trenches,number,length: leaching fields,number, overflow cesspool,number dimensions. "novative/altemative system Comments(note condition of soil,signs hydraulic technology.narne of etc.): /J y / / failure,level of ponding,damp soil,condition of vegetation J d f 41 vac , /4 Z, CESSPOOLS: cesspool must be pumped as part of in spection)(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 constnretion: Indication of groundwater inflow(Yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetatio n,etc.): PRIVY:,/nocate 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.): page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 oe 1 /"a f h Aff r-PU 09(O / Owner. vC4 Date of Inspection: m2 a 0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 143 611 3S� /yy Ll �J page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) FzvWj1y Address: � 3 i-la of Awner. _ pate of Inspection: q �p SITE EXAM Slope Surface water X Check cellar 3 Shallow wells Estimated depth to ground water a feet Please indicate(check)all methods used to determine the high ground water elevation: 7 from system design plans on record-If checked,date of design plan reviewed. rved site(abutting property/observation hol thin 150 feet of SAS) Checked with local:Board of Health-explain: Checked with local excavators,installers-(attach Laceta-t—ion—) Accessed USGS database-explain: You must de!p' ow you established t igh gr d orate el at ion: .�, m� . 0 e w _� e • ` 00,0 C) 0,0 coo , J� 02 �•� SP�oe �q �o �- a 2 t • w OR FILTER FABRIC f ER „ - 9$.05 MAX. ", VENT T N PP 4 CAST IRO PIPE f+A , 3.00 95.E MIN. NOT REQUIRED (OR EQUAL)MINIMUM PER PITCH 1 - 4 / F7 FLOW z LEVEL RS TEE z U� FLOW LINE DEPTH HOER ; TEXTURE',, - COLOR " MOTT, . ' - OVER,.'':, ' 0-11" FILL NO 11-- 4- 1 A .' LOAMY SAND OYR 1 /, R ROOTS 1 .-.:.: 4 29 B LOAM SA,N � Y D � i YR6 6 �: / ��` T`. ROOTS 29-132" : Cl ICOARSE :SAND 2 S Y7 4 -: - 1 32 7. ©C3C©C7C}L7L7Q 87«3 ELEV, 9 Cii} _ Q � N4 WATER ENCOUNTERED AT �. ELEV, ° MIN. � __- o 96,03 a LE a - ._. Q d Q Q Q Q CI L�VEL 0 9i3.4 " _. $ S a V. ,7 _ 6.JADD : a _. ELEV..... �_��_ D A �. 9 .9 ELEV. ___.___ - ELEV. 5 3 v ClQ©©C7LiCJ� BAFFLE - DISTRIBUTION o :<© aa ELEV. E« 0o Q.*3 � ©Q E= © L7Q 0 30 , ET LI Ufb OUTLET aa o ELEV.. m .�9.3._.. QEPIH TO BEWATER TESTED -2 500 GALLON. GALLEYS WITH 4 FEET 14 INCHES IN 5 ET 19 CHES FEET �► F RE AN ONE OUTLET I MORE THAN N N A N STONE # Z' F 4 NC�{ES 6 ET 2 7 ;JET29 INCHES A E N FIRM AS TO BE I BASE) ( } N FORMATION 13 X 5 X2 TRENCH 2 _ z WELL �i A �..._._ 60 �a Z E 4 INCHES . � ,,. . 8 FEET 3 CHE 4� p { 132 , _ 87.4 3 4 TO `1 1 2 CLEAN INDEX NO W� ATER .:ENCOUNTERED- AT- ELEV. -� .; DOUDOUBLE WASHED STON E AD,�iST � . F OF FINES FREE F E ! _ g�q USGS .PROBABLE WATER TABLE -ELEV. NUMBER OF BEDROOMS ' GARBAGE DISPOSAL: UNIT SEWAGEDISPOSAL PROFILE OBSERVED' WATER TABLE ELEV. - _...__._,,. . NOT TO SCALE BOTTOM (OF TEST HOLE ELEV. _ TOTAL ;ESTIMATED FLOW _.. ( 110 GAL/W/DAY X ..,. _; : W) _mo_ GAL./DAY REQUIRED SEPTIC TANK CAPACITY --0-60- GAL, - ACTUAL SIZE OF SEPTIC TANK (E)GSTiNG) _j.(&CL GAL. SOIL CLASSIFICATION ..._J_._ DESIGN PERCOLATION RATE S ..Y MIN./IN. uAr EFFLUENT LOADING RATE GAL./DAY/SF. LEACHING AREA 47?.00 SO. FT.. (1 "3XX25)+(3$X=) LEACHING CAPACITY (AREA,X RATE) �.024 GAL./DAY 477.00 X 0.74 RESERVE LEACHING CAPACITY _xQti..E.- "GAL,/DAY x 97.50 NOTES- 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. x 97.62 TITLE 5 AND THE TOWN'S RULES AND .REGULATIONS FOR ( �. .-._:.... � g7.00 �j �� .qss THE. SUBSURFACE DISPOSAL OF SEWAGE. / f 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO T WITHIN 6" OF FINISHED GRADE. �1 DROOs t % N 3. ALL COMPONENTS OF THE,SANITARY SYSTEM SHALL BE CAPABLE OF L x 98.16 g I YE WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN / x 98.13 , - ---- f 'o. 10 FT. OF DRIVES OR PARKING 'AREA . H--26 LOADING SHALL BE x 98.44 �F �o USED UNDER OR WITHIN 10 FT. OF DRIVES OR :PARKING AREAS. / x 98.13 /'� FND, e PN 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL 7.8 LOT 9 , r TAR\ BE MO,, -',TARED IN PLACE. 12,879.0 .t S.F. 5. NO DETERMINATION :HAS BEEN MADE AS TO COMPLIANCE WITH \ DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO \ OBTAIN SUCH DETERMINATION FROM APPROX*IATE AUTHORITY. 98.22 1000 GALLON x 98.38 t 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR . `�-._ � 1 IS TO CALL 'DIG -SAFE" AT 1-888-344--7233 AT LEAST 72 HOURS f SEPTIC TANK PRIOR TO COMMENCING WORK ON SITE. SOIL', TEST 1 J i._ 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS I SOIL ii D. '� SITECONDITIONS PRIOR ,TO COMMENCING WORK ON SITE, ANY VARIATION O; / r OF MAgSq ` IS TO BE BROUGHT TO .THE ATTENTION OF THE DESIGN ENGINEER «. TEST 2 BOX ey ; �� �; 98.60 ROSIN IMMEDIATELY. tz e <. % . 0 ,: 0 8. - PARCEL IS IN FLOOD ZONE X ' O - lQ�r w1L► 1A�• -� f N 9. LOT 'IS SHOWN ON ASSESSORS MAP . 271. AS PARCEL ... �� ` ' �' Vdi 10. `EXISTING LEACH PIT IS TO BE PUMPED AND BACKFILLED OR REMOVED. 98. 000 4. C� , ts0 q� p �� 11. THE INSTALLER IS TO GIVE THE ENGINEER A MINIMUM OF 48 HOURS 00 G �� 0 ` / `� `L (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION NUMBER BELOW c� 10fl W3. ? � 4' 1' 98.27 �G1STEQ Q� ( )' x 99.11 APPROVED.- BOARD OF HEALTH / x 98.49 (199 x 98.80 `q % DATE AGENT, x 98,47 ''f , MASS. PROPOSED SEPTIC DESIGN FOR lb FANARA 1 LOC. , 23 MARKS WAY x 97.44 BAR i'STABL.E, MASSS. H YANN! SWEETSTE 2 ' 203�SETUCKET ROAD / 508- P. 0« BOX 713 f Z c 385-6900 SOUTH DENNIS, MASS. 02660 LEGEND:140cvs MARK'S `' w EXISTING SPOT ELEVATION 00,0 EXISTING CONTOUR----00----� `VZ DATE SCALE , s> > FINAL SPOT ELEVATION DEC. li , 2�� 1 = 2O FINAL CONTOURSOIL TEST LO�- UTILITY POLE CATION REV. ` N, 10, 201 8 ,tt}B N0. 7957-00 TOWN WATER -W W CATCH BASIN ,mj GAS LINE C. CLEAN OUT .� LOCATION` MAP REv, SHEET 1 OF 1 CESSPOOL C.P. 0 C. S8 PRO✓ 7957--00 dw 79.57-SA5DK7; 2017 SWEETSER ENGINEERING DEPTH F10RI2, TEXTURE COLD R MOTT., '�:" R OTHER 0-11» FILL' NO 1-- i 14 A LtOAMY SAND 10YR4/ 1 T , ROO S 14--29 B LOAMY SAND 1OYR6/6 ROOTS -'n � 29 .1 2 ClC1 =": COARSE SAND 2. Y7 4 `. :