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Home My WebLink About0160 MARSTON AVENUE UNIT UNIT 1 - HYANNIS CONDOS } 1 I -MARSTON AVENUE—Harbor Village; Hyannis __� -_-- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) Al m LI DATA U, l7 i,r;.l( art cc� Posta O tt�_ J �! /✓4t!}�C9 - �� d� L Certified N ;postmark f Barnstable �Ol`7 Barnstable i Return Receipt,Fee eNre l AkArriaimMy S4 (Endorsement Require JJ l �+�7-�^ c �^ Restricted Delivery Fee ` `yl J SeA v ices Depa$tmen� (Endorsement Required) / d = " Health ]Division Total Postage&Fees � �P Aic He 20 � Sent To Vincent Cardillo in Street, Hyannis MA 02601 .; lid ----------------- 1164 Beachcomber Court Street,Apt.No or POB°X"°. -_ Osprey FL 34229-9702 y City,State,ZIP+4 � Thomas A.McKean,CHO 2-1010-0000-2848 -1506 April 8, 2013 t i VINCENT CARDILLO 1164 BEACHCOMBER COURT IMPORTANT NOTICE OSPREY, FL 34229-9702 Map &Parcel: 288- 180— OON Map &Parcel: 288-.180 — OOP The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic- 'directs you to connect your dwelling, at 160 Marston Avenue system. This letter ,. Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER Q THE BOARD OF HEALTH ornas . McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEwER connectEetters Stewart Creek Sewer ConnectsVv AILING L.etA Sewer 2Po Merged 3-29-13 Yr2015.doc r. U.S.POSTAG E>>RTNEY BOWES Of`"E Town of Barnstable Public Health Division g ow BARNBTABLE. C 'MA88. ,p 200 Main Street •• - .. '�OrEO�Ap1•� Hyannis,MA 02601 I �r �� '•a 02 02601 006. 0001383424 APR. 08. 2013. VA 7012 1010 0000 2848 150L �. U.S.POSTAGE>>PITNEY eOWES A? � �' � •• _`ice � ::::: �� •e` ZIP 02601 0 ..�� i . �•: 02 1VY ®00.00 B N I!. '. 0001383424 APR. 09. 2013 Vincent Cardillo. �.e Beachcomber Court c vc -osprey, FL � F-- ;N L . E 339 DE 1 DD 0 4/30/:' 3 ... L' T 4!7 A�.. T Y9 C'C R:I TY IA D - f IUNC- d-1MED !sc. . -02601-40ozoo 9 y a. ..i: 0� 601,@4—:..002 •:1.1�1:d2tl l,Edlll131.!l.!ll:1.I1:h11jls,iIT!!!t2?.l011!lf l!'!e�;d:d -� w a ru rLi ., e.. O - OFF) CIAL -. ti Pos $ Certified FetV RI�3 Return Receipt Fe APo tI O (Endorsement Requir Z �Q re Restricted Delivery Fee EZI (Endorsement Required) �QGJ C3 Total Postage&Feesru V THOMAS &PAULA O'CONNOR ram- 4 WINSLOW ROAD WESTWOOD, MA 02090 1 Certified Mail Provides: a A mailing receipt `t a A unique identifier for your mailpiece t a A record of delivery kept by the Postal Service for two years Important Reminders: 4 a Certified Mail may,+Oa�NLY be combined with First-Class Mail®or Priority Maile. a Cert .. r •i 6 r ified Mail_is not available for any class of international mail. a IV0 SURANCEtiCOVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee)a'Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required..- le a For antadditionallfee, delivery may be restricted to the addressee or addressee'§`authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery': a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when.making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONSENDER: COMP'LETE THIS SECTION, COMPLETE THIS ON DELIVERY -■ Complete items iy,2,and 3.Also complete A. Signatu i item 4 if Restricted Delivery is desired. X ❑Agent. ■ Print your name and address on the reverse 0 ,ddressee j so that we can return the card to you. B. ved by( hied Na ) C. Dat f D ivery ■ Attach this card to the back of the mailpiece, G�J�✓A pr on the front if space permits. D. is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No � �THOMAS & PAULA O'CONNOR 4 WINSLOW ROAD WESTWOOD, MA 02090 s. IFCeS�eqficeType � L�Certlfied Mall ❑Fxpress Mafl ❑Registered IWRetu eceipt for Merchan se ❑Insured Mail ❑C.O. +� 6o 4: Restricted Delivery?(Extra Fee) es 2. Article Number 7�12 1. (Transfer from serv/ce 1abeo.,i i'�i �' '1 .t` °a '1010 i0000 2848 0622 e y I PS Form 3811, February 2004 Domestic Return Receipt 1,02595-02-M-1540 UNITED STATES POSTAL SERVICE &Fees. ....... . PP gPaid a Sender: Please print your name, address,* and ZIP+4 in this box Sewer Connect Public Health Division I ,Oa Town of Barnstable 200 Main Street Hyannis,MA 02601 Town of Barnstable Barnstable Regulatory Services Department MA"micaC"" f IiARNSPASM ' 6 9 , ' Public Health Division f° 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#10 12-1011-0000-2141 -0622 March 28, 2013 THOMAS &PAULA O'CONNOR 4 WINSLOW ROAD IMPORTANT NOTICE WESTWOOD, MA 02090 Map & Parcel: 288- 180�pod- The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF T BOARD OF HEALTH omas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons,Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc f + y 1 i Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: _ l,ttp://www.lown.barnstable.ma.us/cdb!� (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.towii.barnstable.nia.us/PLiblIcWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. :\SEWER connectTetters Stewart Creek Sewer ConnectA�MAILING LetA Sewer 2P 3-2 -1 s Merged Q g g 8 3 Y 2 1 r 0 S.doc COMPLETE • ON DELIVERY ONComplete items 1,2,and 3.Also complete A. g ure item 4 if Restricted Delivery is desired. X ❑Agent ■; Print,your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Print d Name) C. Date of Delivery I ■ Attach this card to the back of the mailplece, I or on the front if space permits. D. Is delivery addressANff �t=f n item�l1,'❑Yes RICHARD & CARLEEN BARJ,GHT If YES,enter del( addreMb io ::; �o No PO BOX 4.83 Q TIVOLI,NY 12-583::;- 3. Se 'ce Type Certified Mail �Q press Mall 6 0 ( �Registered :Retum Re or Merc d' e ❑Insured Mail ❑C.O.D. I �6 4. Restricted Delivery?(Extra Fee) es 2. Article Number _1 ransfer from service i'abeq 7 012 1010 0000 2848 0 813 PS Form 3811,'February 2004 Domestic Return Receipt 102595-02-M-1540 :I UNITED STATES POSTAL SERVICE . ' w .r..,�:�,�.:., ,p...,e �. First- czF4 :„;�F? . 3,' >'P �.. PO a es Paid I US� mot , I ,- Permit 133;G-10 .rN'�r.�J., d. i A y�y. L },y{, 5Y u 'N's-: � 'n��.�n�.�� s 5e'a all •�' S�: Sv ��y�: Sender; Please print your name, address; I Sewer Connect Public Health Division U8 Town of Barnstable 2 00 Main Street , I Hyannis, MA 02601 ' I �'. r,i CID . O co L USE Pasta rti C3 Certified F 0�6o cn Po tmark C3 Retum.Recelpt F Q Here n i3 (Endorsement Require ) �w Restricted Delivery Fee 0 (Endorsement Required) � `a C3 Total Postage&Fees $ a RICHARD & CARLEEN BARIGHT PO BOX 483 TIVOLI, NY 12583 . Certified Mail Provides: e A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: is Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. f m For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". c If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail I receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(R(?verse)PSN 7530-02-000-9047 .:. ------ - - '!A I Town of Barnstable Barnstable Regulatory Services Department URmIdcaC j iA MASS I ` �0� Public Health Division a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0813 March 28, 2013 RICHARD &CARLEEN BARIGHT PO BOX 483 IMPORTANT NOTICE TIVOLI, NY 12583 Map & Parcel: 288- 180—,"'& The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF T BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc — u Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You:must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: lit.tp://www.town.barnstable.ma.us/cdb2 (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/Pub]1cWorksTecli/sewerinstalIers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer ConnectAMAIL.ING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc .r- SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature l item 4 if Restricted Delivery is desired. X ❑Agent I ■ Print your name and address on the reverse e�f•-----u`Addressee so that we can return the card to you. B. Rece d by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. _L I K I f 3 ALBERT & LINDA KURINSKAS, TRS. 4IIy address different from item 1? ❑Yes Anter delivery address below: ❑No KURINSKAS (BARNS)NOMINEE TRUSS -L8.MILL POND ROAD WEST BRIDGEWATER, MA;02379 y --- --j ype Bla Certified Mail ❑. ss Mail ❑Registered etum ceipt for Me an e ❑Insured Mail ❑C.O.D oS 4. Restricted Delivery?(Extra Fee) es 2. Article Number ( 7 012 111010 (0 0 0�Ot;2 8 4 8 p 0 6 3 9 (Transfer from service labeo 0 A f PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 i 1 UNITED STATES POSTAL SERVICE A dJ�,.. izalait 0 ga.Upss Paid I • Sender; Please print your name, address, an 2tP41 n.this"bo `"n I Sewer Connect Public Health Division Town of Barnstable I 200 Main Street Hyannis,MA 02601 Y Cr M I I I I I I O • •' F I C I CO Posta $ 026+Q r11 or 0 Certified F rk 0 Return Receipt Fee 0 (EndorsementRequir Q nCj Her C3 �t Restricted Delivery Fee ?. O (Endorsement Required) O Total Postage&Fees r ALBERT & LINDA KURINSKAS, TRS. o KURINSKAS (BARNS)NOMINEE TRUST 18 MILL POND ROAD WEST BRIDGEWATER, MA 02379 J 1 Certified Mail Provides: a A mailing receipt o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. o Certified Mail is,n Jai ilable for any class of international mail. a NO INSURANCE'COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider`nsured or Registered Mail. a For an'additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. E a For an a additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted�elivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. PS Form 3600,August 2006(Reverse)PSN 7530-02-000-9047 __.. .......... . c . INME Town of Barnstable Barnstable .� Regulatory Services Department ;e�ieaC"I j MRNSCAB[�, 9. , ' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2141 -0639 March 28, 2013 ALBERT &LINDA KURINSKAS, TRS. KURINSKAS (BARNS) NOMINEE TRUST 18 MILL POND ROAD IMPORTANT NOTICE WEST BRIDGEWATER, MA 02379 Map & Parcel: 288- 180 The Department of Public Works informed us that public sewer,lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE B ARD OF HEALTH omas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc v Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. i SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstab]e.ma.us/cdb� (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PLtbllcWorksTech/sewei-installers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors,please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer COnnects\MAIL.ING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc COMPLETE •N,, COMPLETE THIS SECTIONON DELIVERY I ■ Complete items 1,2,and 3.Also complete A. Signature ]�' I item 4 if Restricted Delivery is desired. (""'Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Rec ' d by(Printed Name C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. 13 D. Is delivery address different from item 17 ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No (.JANE DAVIS & JEA K ` %HNCOCK, JEAN 38VLUE HILL RD -�"° ' 3. ,Se ice Type CI�STER,VT 05143 Qb Certified Mail ❑ press( all _ ❑Registered• Wwikturn ecelpt for Merc ndise ❑Insured Mail ❑C.O.D. �� p j' ` 4. Restricted Delivery?(Extra Fee) Yes 2. Article Number 'l 7b,121i 1010 2 2 0 2 2 8 4181 0 6 5 3 (7hinsfer from service labeq r PS Form 3811,February 2004 Domestic,Return Receipt 102595-02-M-150; t - UNITED STATES PQs �4�� V }V s First-Clas ` 0. Pos USPs tage 'aid t I .Permit No 0 I • Sender: Please print your name, address, 'rtf o I N Sewer Connect Public Health Division "( a Town of Barnstable 200 NtMn" Street Hyannis,MA 02601 lip 1.11'Iij1iIIiIII!if if i1,FII711III 111h IIIJ lij j';l'II;111I''I�I' F � m Ln o - ut OFFICIAL I ru p Certified FLo p Rsem Receipt Fp (EndorsementRequirepRestricted Delivery Feep (Endorsement Required) r� C3 Totai Postage&Fees P� ru JANE DAVIS &JEAN HANCOCK p % HANCOCK, JEAN 380 BLUE HILL RD CHESTER, VT 05143 Certified Mail Provides: o A mailing receipt e o A unique identifier for your mailpiece 0 A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& o Certified Mail is ni i•available for any class of international mail o NO INSURANCE.,COVERAGE IS PROVIDED with Certified Mail. For valuables,,please consider Insured or Registered Mail. e For an additions.fee,a Return Receipt may be requested to provide proof of deliveryjd obtain'Return Receipt service,please complete and attach a Return Receipt(PS Form 3611)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return recetre USPSe postmark on your Certified Mail receipt is required.\ •lip" 0 "( o For an additional•fee1 eilivery may be restricted to the addressee or addressee's authorized agent:Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT..Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 t Town of Barnstable Barnstable Regulatory Services Department mm"e`cacfi" BMWSTABM 3 Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas-F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0653 March 28, 2013 JANE DAVIS &JEAN HANCOCK % JEAN HANCOCK 380 BLUE HILL RD IMPORTANT NOTICE CHESTER, VT 05143 Map & Parcel: 288- 180- COF The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE BO RD OF HEALTH Mc ean, R.S. C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. Q:\SEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc r Public Health Division March 28 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. { I LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/edba (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/Pub]1cWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer ConnectAMAILING LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc • / • • • DELIVERY ■ Complete items 1,2,and 3.Also complete A. Si nature item 4 if Restricted Delivery is desired. ❑Agent XL4■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B.#eceived by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, , or on the front if space permits.. _D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: t't I r /y'If YES,enter delivery address below: ❑No -� .EUGENE & JANET S I T. I :222WERSEY ST Hll�ffi MA 02043 sA l e`Type I3Certified Mail O F,xpre all _ 1❑Registered eturn ci§l'pt for Me handise O ❑Insured Mail ❑C.O. S O �sS 4. Restricted Delivery?(Extra Fee) p Yes 2. Article Number T??T-*-- ---— (�ransfer from servlce labeq t 0120101010 ; 2$4z8; 7 76 - - - PS Form 3811,February 2004 Domestic Return Receipt 102595.02-M-1540 I UNITED STATES POSTAL SERVICE First-Class Mail Po tage&Fees Paid LISIPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • i -----Sewer Connect ,M Public Health Division �0Town of Barnstable os 200 Main Street Hyannis,MA 02601 I I I IIIiI'Iri.{illLflii.Ilia'Iiti,"i�}�Iil,liilj��,llilliraiillllilil ili [ti .. I I e cc Postew s flJ � Certified F `�rj MA F0? Return Receipt Fee. �` Postmark �0 Mfg (Endorsement Requir ' Here �,� Restricted Delivery Fee ; t g M (Endorsement Required) - t4 M Total Postage&Fees \ � C,? ru EUGENE & JANET SMITH ram•- c 222 HERSEY ST ` HINGHAM, MA 02043 Certified Mail Provides: o A mailing receipt n A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. a Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail For valuables,please consider Insured or Registered Mail. a For an additional•fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt seance,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return.receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. j IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Bar A �.� � Regulatory Services Department �e` j SrAH>� I I ` Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0776 March 28, 2013 EUGENE &JANET SMITH 222 HERSEY ST IMPORTANT NOTICE HINGHAM, MA 02043 Map & Parcel: 288- 180—pQ The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER THE BOA D OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons,Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\ 1A1LING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc y Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdbE� (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.bai-nstable.ma.us/PLtbIIcWoi-ksTech/sewerinstalIei-s. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connecALetters Stewart Creek Sewer Connects\ IAIL.ING L.etA Sewer 2Pgs Merged 3-28-13 W2015.doc • • OMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent, ■ Print your name and address on the reverse X ❑Addressee so that we Can return the Card to you. B. Received by(Printed e) C. Plate of Delivery is Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No MES H. ROWE, TR. C S CAPE TRUST t 5008,.GLENBROOK RD NW Q 3. �Se ' e Type WA HINGTON, DC 20016 `b d ertified Mail ❑ press Mail ❑Registered [iReturn pt for Merchan i e ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) es 2. Article Number 7 012 1010 0000 2848 0 6 6 0 (Transfer from sere/ce labeo PS Form 3811,February 2004 Domestic Return Receipt 102595.02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 I _ • Sender: Please print your name, address, and ZIP+4 in this box • I I Sewer Connect a Public Health Division Town of Barnstable i 200 Main Street Hyannis,MA 02601 I I I I I II I I I I UPS Pc stal ServiceTM CERTIFIED MILTM RECEIP�T� � : Pia (Domestic Mail�Oniy,No:Insurance�Coverage Provrded) � Forilelivery,information,visit our,,website aat wvirw.usps.com® _■ -LOTIMR v .._ Certified Mail Provides: a A mailing receipt o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years p Important Reminders: a Certified Mail.may ONLY be combined with First-Class Maile or Priority Mail& o Certified Mailil.is not available for any class of international mail. _ a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For ar additio" nal fee,a Return Receipt may be requested to provide proof of delivery.To obt�j Return Receipt service,please complete and attach a Return Receipt(PS For ma3811)to the article and add applicable postage to cover the fee.End4&Ase mai 'e, 'Re eceipt Requested".To receive a fee waiver for a duplica return rSe postmark on your Certified Mail receipt is regwred� }l' a For ansad delivery may be restricted to the addressee or addressee s agent.Advise the clerk or mark the mailpiece with the endorsemerlt+Rest�ric>ed Delivery" a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT-Save this receipt and present it when making an inquiry. s PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 { r Town of Barnstable Barnstable .�~C� N-ABiCCBIty ; Regulatory Services Department dC BAMWABLE; I Public Health Division 111 f 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0660 March 28, 2013 JAMES H. ROWE, TR. C S CAPE TRUST 5008 GLENBROOK RD NW IMPORTANT NOTICE WASHINGTON, DC 20016 Map & Parcel: 288- 180-00C-r- The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. 'Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection,please see the reverse side of this page. PER ORDER OF THE B ARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. $ QASEWER connect\L.etters Stewart Creek Sewer Connects\MALLING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc y Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://ww\v.town.barnstable.nia.us/cdb (under the"CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ina.us/Pub].icWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer ConnectsWAUNG L.etA Sewer 2Pgs Merged 3-28-13 Yr2015:doc COMPLETE THIS,SECTi6N ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig re - Item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received by(Pdnt N C. Date o Delivery ■ Attach this card to the back of the mailpiece, �� or on the front if space permits. D. Is delivery address different from Item 1? ❑Yes A. Article Addressed to: If YES,enter delivery address below: ❑No STANLEY & DEBORAH JENCUAS 9 5 EMILY LANE Ott NORTH EASTON, MA 02356 3. se 'ceType 7CerUfied Mail ❑ press Mail ❑Registered lietum pt for MercFi Ise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) Yes 2. Articie.NuIn i : ;; ; :( 7 012=: 1010 ' p p p` 8 4 8 6 7 7F (transfer from service Meo�Q�Y- J! I i 1 e° r, t,:. ' 2 PS Form 3811,February 2004 Domestic Return Receipt 102595.02-M-1540; y p UNITED STATES POSTAL SERVICE Fft1=G4s Maii; Pee§Paid e. �nr ..,. ...;.i:.�..•';•.,, v:;�,r.t>..; ` ..,,� .N.a.41fa::. Sender: Please print your name, address, art"�Z,t,+#'in this C Sewer Connect dra J 4 Public Health Division 4 Town of Barnstable 200 Main Street Hyannis,MA 02101 I I I I l�lihi�iii�'il��lisiii�liii.i��li�iiili�►�ii�►ililFi'i!!�'Ii!�il - R- 12 c. C3 .- iC0 0 F F I Co Postag $ Certified FeW C3 y. ark O Return Receipt F e M (Endorsement Requir J� are C:3 Restricted Delivery Fee ..0� 1=3 (Endorsement Required) fJ O Total Postage&Fees $ ! 6 rrq STANLEY& DEBORAH JENCUNAS 15 EMILY LANE NORTH EASTON, MA 02356 Certified Mail Provides: o A mailing receipt io A unique identifier for your mailpiece e A record of delivery kept by the Postal Service for two years Important.Reminders:, . o Certifled"Mail may,bNLY be combined with First-Class Maile or Priority Maile. o Eekified Maii is n of ayayable for any class of international mail. ; a1NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For val a'le��please conside'�rinsured or Registered Mail. e Foq an ad rig,,fee, Return Receipt may be requested to provide proof of t del�Yery.Too taih'Retw n Receipt service,please complete and attach a Return 1Red ipt(PS Fo"r"m`r38+11-16 the article and add applicable postage to cover the fee: -. ors e mailpiece;Return Receipt Requested".To receive a fee waiver for a duplicatewetam receipt,a USPSe postmark on your Certified Mail receipt is reg ire d. • o For an aifdifional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". ® If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 i Town of Barnstable Bar nstable t�r ti Regulatory Services Department �'er`ca�j f BwARNS ASM I 9� '039. Public Health Division s63p �� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0677 March 28, 2013 STANLEY &DEBORAH JENCUNAS 15 EMILY LANE IMPORTANT NOTICE NORTH EASTON, MA 02356 Map & Parcel: 288- 180 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection,please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\i.etters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc t Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a rinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through ygur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barn.stable.ma.Lis/cdbg (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.nia.us/PLib11cWoi-ksTech/sewerinstalIers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connectTetters Stewart Creek Sewer Connects\MAIL.ING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc COMPLETE •N COMPLETE THIS SECTIONON DELIVERY 11111 Complete items 1,2,and 3.Also complete A. Si ure item 4 if Restricted Delivery is desired. X ❑Agent E III Print your name and address on the reverse �� so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. _n_._is.delivery address different from Rem 1? ❑Yes 'LEWIS & ELIZABETH GLANVILLE JRS. S,enter delivery address below: ❑No GLANVILLE REVOCABLE TRUS;T.. 507'NORTH HUNTINGTOXAVE MONTEREY PAW"CA 91:754- } ' _ _ ��??ice Type =[ 'Certified Mail re Malli7 Registered um eipt for Merc Ise ❑Insured Mail .D. C/ �. �O 4: Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7�12, ,1010 .�0O4 284.8: 0684 (transfer from service.iabeo PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M•1540 I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS I Permit No.G-10 I - •I address, and ZIP+4 in this box •Sender: Please print your name, I I ' Sewer Connect I I I� Public Health Division { Oa Town of Barnstable 200 Main Street Hyannis, MA 02601 I 43 I• 0 c Postag $ rU ru Certified FEW g M RetReturnRecei tmark pt Fe Here M (Endorsement Require o Rest Delivery Fee w � (Endorsement Required) r-R V C3 Total Postage&Fees ri ru LEWIS &ELIZABETH GLANVILLE, TRS. o GLANVILLE REVOCABLE TRUST 507 NORTH HUNTINGTON AVE I MONTEREY PARK, CA 91754 Certified Mail Provides: ' I c A mailing receipt o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders.. o Certified Mail may ONLY;be combined with First-Class Mail®or Priority Mail®. n Certified-Maifis no'bivilable for any class of international mail. o NO/INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuab1s-;p'fee`as considgr1nsured or Registered Mail. e For an addition dbe,a R*rn Receipt may be requested to provide proof of del(very� �'b � To obtain4 etur , eipt service,please complete and attach a Return Receipts(,pS Form 38Ifo the article and add applicable postage to cover the fee.Endit mailpiec "Retum Receipt Requested".To receive a fee waiver for a duplid9f4#return-rei 1pt,a"USPS@ postmark on your Certified Mail receipt is requIred:,,�',.,'U - n For an additional'"e, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery': e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 --- -- -------- - - ------- --------- - Town of Barnstable .� Barn Regulatory Services Department j ericaC"j HARN5TASM. I ' 'NAB039�- Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0684 March 28, 2013 LEWIS &ELIZABETH GLANVILLE, TRS. GLANVILLE REVOCABLE TRUST 507 NORTH HUNTINGTON AVE IMPORTANT NOTICE MONTEREY PARK, CA 91754 Map & Parcel: 288- 180—6 OT The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection,please see the reverse side of this page. PER ORDER OF THE BOA OF HEALTH T omas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons,Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc I 1 Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstab]e.nia.us/cdb!� (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PLtb11CWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer Connects\MAIIdNG LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc SECTIONSENDER: COMPLETE�THIS SECTION COMPLETE THIS DELIVERY. M Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. f ❑,..,Agent ■ Print your name and address on the reverse �...�"QAddressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 11.Article Addressed to: If YES,enter delivery address below: ❑No HOR VILLAGE CONDO ASSOC %`1`'INDA A KURINSKAS, TREAS. 'j 8 MILL POND RD 'WENT BRIDGEWATER, MA 02379 3. See Ice Type f certified Mail ❑,Express Mail ❑Registered M eturn R or erc e ❑Insured Mail 0 C.O.D. 4. Restricted Delivery?(Extra Fee) g 2. Article Number 7 012 1010 i f OOOo. 284a : a7o7 (rransfei from service labeo t !i ! I t�i .{i z z z z i z ,w PS Form 3811,February 2004 Domestic Return Receipt. 102e95-02-M-lM UNITED STATES POSTAL SERVICE F�ir�YMass`TaFail Na...+ d 3 .i 3 t.3; b L�; > a QSta a gi B S��all ! • Sender: Please print your name, address,'and ZIP4�*imlfiis box • ^. :,�, I I d^� Sew; Connect Public Health Division j I I Town of Barnstable I 200 Main Street i. Hyannis, MA 02601 C �I I. I 11 � ilillll 1li1lII � 11r1II1111".111� Iall' n 0 �.. O ro Po $ ni Q Certified FJW C P tm Retum Receipt F Q �v ere. a (Endorsement Requir ; Restricted nt Deliver' Fee � (Endorsement Required) ra 0 Total Postage&Fees $ e ru HARBOR VILLAGE CONDO ASSOC c3 % LINDA A KURINSKAS, TREAS. 18 MILL POND RD WEST BRIDGEWATER, MA 02379 Certified Mail Provides: o A mailing receipt e A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: to Certified Mail may`ONL egmbined with First-Class Mail®or Priority Maile. o Certified Mail is notagailable for any class of international mail. to NO INSURANCE-COVERAGE kPROVIDED with Certified Mail. For valuables;please consider Ins6nid7ot Registered Mail. to For an additional fee;a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt,service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. a For an additional fee—delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,Please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 I - ------- -. Town of Barnstable Barn �r .� ti . Regulatory Services Department NMmaicaC'j sARNSPnBMMAW I Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0707 March 28, 2013 HARBOR VILLAGE CONDO ASSOC LINDA A KURINSKAS, TREAS. 18 MILL POND RD IMPORTANT NOTICE WEST BRIDGEWATER, MA 02379 Map & Parcel: 288- 180 —ooT The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons,Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA1LING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc F . Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to.those of you who need a grinder pump_for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdb (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstabie.ma.us/Pub]1cWorksTecli/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc i • • 60MPLETE THIS SECTION'ONDELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X f ❑Agent ■ Print your name and address on the reverse Gt•-• ❑addressee so that we can return the card to you. 13. R ceive by(Printed Name) C. Dat of Livery ■ Attach this card to the back of the mailpiece, os or on the front if space permits. o f L-kl D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No J®HN & LOUISA NIILWE,� 50I,NT1NGTON ST G#.ACORD,NH 03301' j apr I 3. Se ice Type I! / Se Mall rRe re �ail ❑Registered ef ptfo un Merch dise ❑Insured Mail .D. I �U 4. Restricted Delivery?(Extra Fee) es 2. Article Number 7 012 €1�10=LD S 0 2`8 4'8 0 714 I (Transfer from service labegl.:: :; . : : , PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I I I Sewer Connect d� � s Public Health Division to Town of Barnstable 200 Main Street N Hyannis,MA 02601 A I M I ( �11ll F.i.1111}�I:fllillt. 1111��11llial lil�illi'f91� !1-ll�lti� II O:l F I I co Post. $ru �P u Certified F Postmark Return Receipt Fe s s Q�Here O (Endorsement Require Restricted Delivery Fee (Endorsement Required) J rq / O Total Postage&Fees $ e rq r JOHN & LOUISA MILNE T C3 5 HUNTINGTON ST CONCORD,NH 03301 Certified Mail Provides: o A mailing receipt a A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years 4 Important Reminders: e Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. O NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,"please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required, In For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If,a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ------- - -- - _- - --- -- -------- r Town of Barnstable Barnstable .� Regulatory Services Department AN-AmedeaC j snruvsrnaiae, I I Public Health Division by OR 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 568-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0714 March 28, 2013 JOHN &LOUISA MILNE 5 HUNTINGTON ST IMPORTANT NOTICE CONCORD, NH 03301 Map & Parcel: 288- 180''p0L— The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc L Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a rin�dei pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdb�,, (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PubIicWoi-ksTech/sewei-instalIers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connecALetters Stewart Creek Sewer Connects\MALLING LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc 60114PLETE THIS SECTION COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete A. ig ature item 4 if Restricted Delivery is desired. ❑ gent X ■ Print your name and address on the reverse Ad essee so that we can return the card to you. B. Received by(Printed Name) of ry ■ Attach this card to the back of the mailpiece, or on the front if space permits.. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: if YES,enter delivery address below: ❑No ' HARON KRAVIS PO BOX 46 HAGAMAN,NY 12086 3. s eType f•' Certlfted MailEpn3ssM#06 ❑Registered etum R pt for Me ha Ise ` r ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) s 2. Article Number 2'6 4 8 0721 � .(Transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE_ First-Class Mail Poitage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Sewer Connect Public Health Division Town of Barnstable 200 Main Street Hyannis, MA 02601 I I �I !+I!►l�lrl!!}l�rt}��l��i,1 },la��l,,»}t►�,>>li�lrnl�llllrrlt!! � R v /u . •.. C3 co ... I. I , fcc $ / D)2 0 Q ru Certified F �`C7Retum Receipt F OO (Endorsement Required) 'z(Restricted Delivery FeeC3 (Endorsement Required) C:3 Total Postage&Fees r—1 A SHARON KRAVIS PO BOX 46 HAGAMAN,NY 12086 Certified Mail Provides: is A mailing receipt o A unique identifier for your mailpiece f a A record of delivery kept by the Postal Service for two years f Important Reminders: a Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additionalfee,a Return Receipt may be requested to provide proof of delivery.To obtain'Return Receipt service,please complete and attach a Return Receipt(PS;Form3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. + a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". 1 o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. I IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800;August 2006(Reverse)PSN 7530-02-000-9047 i ti Town of Barnstable Barn �T .�ti Regulatory Services Department j e�ieaC.j BARNSPABM . I Public Health Division 9� s6;q. �� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0721 March 28, 2013 SHARON KRAVIS PO BOX 46 IMPORTANT NOTICE HAGAMAN, NY 12086 Map & Parcel: 288- 180-00M The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs.you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connecAUtters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc r' Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through ygur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.bat-nstable.ma.us/cdb!� (under the"CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.bai,nstable.ma.us/PLibiIcWorksTecli/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connectTetters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m -A �C&E DATA ILA � of Barnstable . rnstabie 3- � W ' Fri Al-MmicaCRY . 4jc�'n Post - $ ,5 j o Services Department XiCertified F ` , Return Receipt F e lic Health Division �, ��s �,, m (Endorsement Requir '� here ] Street, Hyannis MA 02601 20� Restricted Delivery Fee ,` (Endorsement Required) USX C Total Postage&Fees � � 5 y r homas F.Geiler,Director /� GARRICK & KATHRYN BAUER Thomas A.McKean,Cxo 160 MARSTON AVE-UNIT 15 HYANNIS PORT, MA 02647 10100-2848 -0745 March 28,2013 -T GARRICK& KATHRYN BAUER 160 MARSTON AVE-UNIT 15 IMPORTANT NOTICE HYANNIS PORT, MA 02647 Map &Parcel: 288- 180 -C The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling; at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. _ Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE BO RD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering,DPW Enc. QASEWER connectEetters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc r ' • / COMPLETE,THIS SECTIOWOk6ELIVERY in Complete items 1,2,and 3.Also complete A. Si n ture item 4 if Restricted Delivery is desired. ❑Agent_ Is Print your name and address on,the reverse ❑Addressee so that we can return the card to you. Received by(Printed Name) C. Da7P;x, ■ Attach this card to the back of the mailpiece, or on the front if space permits. ;1 " D. Is delivery address different from item 1? ❑Ye 1. Artic1°e Addressed to: If YES,enter delivery address below: ❑No . t DRA ROSS ° H3�]NIS PORT, MA 02647 s. s�eryice Type a Certified Mail �O 513 � ❑ �for Registered �©0 ® u Ise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) g 2. Article Number (Transfer from service/abed 7 012 1010 0000 2'848 0769 TI PS Form;3811,,February 2004 Domestic Return Receipt 4o25s5-o2-M•t54o UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print.your name, address, and ZIP+4 in this box • I A ara Sewer Connect + '4 Public Health Division I IOa Town of Barnstable 200 Main Street j I Hyannis, MA 02601 UUZ I I I I I I I I U.S. Postal,ServiceM r b° DIU, CERTIFIED M,�41L.TM F;ECEIPT � � °`' ' ( mestig MailFOnlyi.No,Jnsurance,Coverage P ov►ded) MFor;diIivery,information,visit our,websiti a-t iA7 W.usps.com® i -■ Certified Mail Provides: a A malting r*pt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: to Certified Mail may ONLY be combined with First-Class Mails or Priirity Mails,. • Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain.Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a dupllicdat return receipt,'a USPS®postmark on your Certified Mail receipt is to For an additional fee, deli ry may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". y o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 t, 1`• �tME 11, Town of Barnstable Barnstable .� Regulatory Services Department N-AmericaCity� .eiutSTAB.c. I 9� " �� Public Health Division 6 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0769 March 28, 2013 SANDRA ROSS P O BOX 36 IMPORTANT NOTICE HYANNIS PORT, MA 02647 Map & Parcel: 288- 180--c9O Q The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. ORDER OF THE B ARD OF HEALTH Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MAIL.ING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc S Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through ygur own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdba (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.lna.us/PublicWoi-ksTech/sewerinstalIei-s. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc COMPLETE THIS SECTION ON DELIVERY ::�SENDER: COMPLETE THIS SECTION ■ Complete items 1,2,and 3.Also complete A. Sign ur item 4 if Restricted Delivery is desired. ❑Agent a Print your name and address on the reverse X'' " ❑A dressee so that we can return the card to you. B. Received by(Printed Name) C. Date p live ■ Attach this card to the back of the mallpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? as -��.,� If YES,enter delivery address below: No �RICHARD & DIANA GHOl�h44 ' C/O CAPE COD COOPERATIVE 25 BENJAMIN FRANKLIN WAY HYANNIS, MA 02601 3. S�e�ice Type I�d'Certifled Mail 13 Express Mall Op,j ❑Registered qi-�eturn elpt for Merchan se ❑Insured Mail ❑C.O.D. "i I NV , h---—I — A 4. Restricted Delivery?(Extra Fee) es 2. Article Number I i 7 012 101 0 1 s 0 0 0 0 2848 0783 (Transfer from service labeqfl PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540; UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I I Sewer Connect Public Health Division ' Town of Barnstable 200 Main Street I Hyannis,MA 02601 M I � I M I Esl�Ilsilili#�'ll�iifi;li�i,li'i11E4i1�I}il�'f'�i1�1,11d1=1il ��l � • � J E m co r%- C3 co IVW cco Postipd, $ ` �t�O j O Certified F C3 p gi ,a Retum Receipt F e ��" Here O (Endorsement Requir O Restricted Delivery Fee (Endorsement Required) r9 rq u O Total Postage&Fees 6 ni RICHARD &DIANA GHORN o ; C/O CAPE COD COOPERATIVE r` 25 BENJAMIN FRANKLIN WAY HYANNIS, MA 02601 Certified Mail Provides: o A mailing receipt r_ n A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: l,r it a Certified Mail may ONLY be combined with First-Class Mails or Priority Mails. o Certified�Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail a For an additt6oalafee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required.\V �. a For an additional.fee, delivery may be restricted to the addressee or addressee's authorized agant.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". - a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 iL . . THE Town of Barnstable Barnstable AFAmadeaCft .� Regulatory Services Department ■A MAS&LE , ` Public Health Division ep' 200 Main Street, Hyannis MA 02601 27F07 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0783 March 28, 2013 RICHARD &DIANA GHORN C/O CAPE COD COOPERATIVE 25 BENJAMIN FRANKLIN WAY IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 288- 180 —C)6 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\L.etters Stewart Creek Sewer Connects\MA1LING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc P Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a ri�pump_for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the a limited time of two years, only from the receipt of the DPW letter,the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barrlstable.nia.us/cclba (under the"CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.towii.barnstable.iiia.us/Pub]1eWorksTech/sewei-installers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connecALetters Stewart Creek Sewer Connects\MAILING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc o - gaA 6V ri l�i July 23, 2009 Town of Barnstable,Public Works Water Pollution Control Division 617 Bearses Way Hyannis,MA 02601 Dear Sirs: Please ensure that this letter reaches the appropriate persons or committees. Since an expensive solution is being pursued to remedy the fact that the water quality of Stewart Creek has been badly compromised, it has spurred us to disclose to you a dirty secret. Look no further than the free standing cottage/condo community of Harbor Village on Marston Avenue, which borders Stewart Creek. Most of the homeowners there are involved in an active short term rental program with an onsite manager. The waste management of Harbor Village has long been cloaked in corruption and complicity. For the protection of Stewart Creek an independent inspection of this septic system is essential. Do NOT accept the septic plan as presented and do NOT use the "inspector"who has consistently signed off on their"inspections"over the years. An independent contractor with a backhoe will reveal an antiquated system with multiple lines connected to each septic receptacle: For the health of the Creek and the community,please investigate this immediately before any more monies are wasted on studies and solutions. Sincerely, Concerned neighbors of Stewart Creek Zt 81 `.:ri N J . I lrl �obww vsn W open • woo*pe®tus 6££Ob"ON f :f I 9. COMMONWRALTH OF MASSACHUSEWS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS MPARTmENT OF ENVIRONMENTAL PROTECTION TITLE 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 160 Marstons Avenue #1 ` f r- Hyannisport -� Owner's Name: Tim Fuller N �' Owner's Address:_pogn_7 7 6 a ,- art �� .� Date of Inspection: i o a Name of Inspector.(please print)_ William E. Robinson, Sr. Company Name: William E. Robinson �iept3e bervice Ja r Mailing Address: P O Box 1 089 Centerville, MA Telephone Number. t 5081 775-w B776 l� �® CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information repotted 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 ofon site sewage disposal systems.I am a DEP approved system inspector pursuant�on 153d0 of Title 5(310 CMR 15.000). The system: ` Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Faits Inspector's Signature: Goa Dute: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health er 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 tepott 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 approxing authority. Notes and Comments `This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I 4 ' Page 2 of i l C OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- 160 Marstons Avenue #1 yannispor Owner: Tim Fuller Date of inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete an of Section D A. Syste Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CtAR 15.303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below. Comments: .u. System Con' itionally Passes: One or mo a system components as described in the"Conditional Pass"section need to be replaced or repaired.The syste ,upon completion of the replacement or repair,as approved by the Board of Health,will pass. t Answer es no or t determined Y N ND in the for the follow statements. f' del Y to 1 "not ermined lease ( ) g p explain. The septic is metal and over 20 years old*or the septic tattle(whether metal or not)is structurally unsound,exhibits s stantial infiltration or c4hration or tank failure is immincaL System will pass inspection if the existing tank is reps zed with a complying septic tank as approved by the Board of Health. 'A metal septic will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the is less than 20 years old is available. ND explain: Observatio of sewage b tlaW or break out or high static water level in the distribution box due tw broken or obstructed pipes) r due to a broke k settled or uneven distribution box.System will pass inspection if(witfi approval of Board f Healthy broken pipe(s)are replaced obsmtaion is r+emved distribution box is leveled or replaced ND explain: The syster required pumping more than 4 times a year due to broken or obstructed pipc(s).The system will pass inspection if�*ith approval ofthe Board of Health): broken J pipt:(s)are replace obstru is nmovad ND explain: i Page of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued); Property Address• 160 Marstons Avenue #1 Hyannisport Owner: Tim Fuller Date of Inspection: —O 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 fai' g to protect public health,safety or the environment. II System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b)that the ystem is not functioning in a manner which vet protect public bealth,safety and the easy"[roament: Cesspool or privy is within 50 feet of a surface water Cesspool or privy"is within 50 feet of a bosdecing vegetated wetland or a salt marsh 2. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a suritace water supply or tributary to a surface water supply_ The system has a septic tank and SAS and the SAS is within a Zone I 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. _ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a priva a water'supply well" Method used to determine distance •'Thi system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacte a and volatile organic compounds indicates that the well is free from pollution from that facility and the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure riteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r 3 Page 4 of t I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Avenue 01 yannispor Owner: Tim u er Date of inspection: D. stem Failure Criteria applicable to all systems: You ust indicate'yes"or"no"to each of the following for ail inspections: Yes)Any Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of cMueat 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.outiet 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 Requ'ued pumping more than 4 times in the last year NOT due to clogged or obstructed pipc(s)_,Number of times pumped portion of the SAS.cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 1004eet 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 w•alrr supply well with no acceptable water quality analysis.£This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (Yes/No)The system faits.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 ystems: To be consi Bred a large system the system must scrvc a facility with a design now of 10,000 gpd to 15,000 hpd- You must indicate tither'yce'or"no"to each of the following: (The following\criteria apply to large systems in addition to the criteria above) Yes no t 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 syste is located in a nitrogen sensitive area(interim Wellhead Protection Area—i WPA)or a mapped Zone 110 public water supply well If you have answered.'yes"to any question in Section E the system is considered a signiftcmat threat,or answered "yes"in Section D ab�ve the large system has fated.1U vwn=r err operator of any large system considered a significant threat and r Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The systemrner should contact the appropriate regional office o[the Department. !i 4 I Page 5 of i l A, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 Marstons Avenue #1 Hyannis port _ Owner: Tim Fuller — Date of Inspection:_ —2 Check if the following have been done You must indicate`fires"or W as to each of the following: Ycs/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 7 Has the system received normal flows in the previous two week period? — —/Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(if they were not available note as NIA) c/ Was the facility or dwelling inspected for signs of sewage back up? 7/ Was the site inspected for signs of break out? L/— 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 _ e b of thaffles or tees,material of construction,dimensions,depth of lrgurd,depth of sludge and depth of scum? v 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 isting information.For example,a plan at the Board of Health. _f_ Determined in the field(if any of the Wi1111e criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CMR 15302(3)(b)j 5 Page 6 of I 1 t; OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Marstons Avenue #1 Hyannisport Owner: Tim Fuller Date of Inspection: —o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15103(for example: 110 gpd x P of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no): cJ Is laundry on a separate sewage system(yes or no):A-a [ifyes separate inspection required) Laundry system inspected(yes or no):,L4i U Seasonal use:(yes or no): �- 5 N/A , Water meter readings,if a actable(last 2 years usage(gpd)}: Sump pump(yes or no): A-c1 Last date of occupancy: COMM ERCIAL(I"USTRIAL Type of establishmen Design flow(based n 3l0 CMR 15103): gpd Basis of design flo (seats/persons/sgketc.): Grease trap pres t(yes or no):_ Industrial waste olding tank present(yes or no):— Non-sanitary aste discharged to the Title S system(yes or no):_ Water meter 5tadings,if available: Last date of ccupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Y ij�, 1)z Was system pumped as part of the inspection(yes or no). If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for pumping: TYP F SYSTEM _ optic 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): Approximate age of all components,date installed(if known)and source of information: / <A' 8' 1i Were sewage odors detected when arriving at the site(yes or no): � o 6 l I V.igc 7 of t l OFFICIAL INSPECTION FORAI—NOT OR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION V0RA1 PART C SYSTEM INFORMATION tcontinucd) Property Address: 160 Marstons Avenue #1 yannispor. 0►►ncr. Tim Fu er Dolt of Inspcctfon: ` l•�E.—a UUILUING SMEII(lucatt un silt plan) Dcpui below grade: '9 % 10alcrials of cons(ruction:_cast iron _du PVC_oUtcr(cxlrlail►). NUKE front private water supply►eelt or sucliun I41c:_ Cununcnts(on condition of jousts,Vu►ting,cvidutcc of Icak-age,cic.): SEPTIC TANK:Z�locatc on sift plan) Depth below grade:—Jq— � Mistrial of construction: Leunuctt_111eta4 fiberglass pulyetitylene _ulhci(cx lain p ) lr tall is rt►etal list age:_ Is age eunftrustd•by a Certificate of cuttsplianee(yes or Ito):_(11131d) a copy of Dimensions: Sludgc depth: Distance from top of sludge to bui►ul,t of uulicf ice or baffle: 5cu111 thickness: - Distancc from tup of scum 10 lop uroullet ice or baffle: Distancc Dorn bunum ur scum to butiorn of outlet tee or I 11c: How were dimensions dctcnninal: 0 -[;'=—� � r, 1j Ctrtml,tntS(Oil pumping rtcuu►rncndations.inlet and outict tee or batik corrdiue,u.ShuUmal inlc6rily,Hyoid Ic�•cly as related to outlet invest,evidence of Itaka C.tic_); 9 GtIEASE Tl I':_(lucatt on silt plan) Depth below adc._ Material urc nstructiun:_cumicic metal_fibrr);1ass_tsul}ctltylusc _oAtcr (o,plain): Dinicnsions Scum tluc tcss: Distance G in top of scull,to cup of uutict tcc or battle. _ Distance om bottom of scum to button►of uutict let ur bafllc: Dalc of I t pumping: Conune s(on pumping teeu►u►ttcttdatiut►s,inkt and uutict tee err bank eund►utsa,structural u►tc6tily,liquid IC►"Cli as lelalc to oulict ulvclt,ct•idcllcc of IcakaFe,ete.j: 7 fags 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSL•'SSNJLN"1 S SUBSUIVACE SENVAGE- DISPOSAL SYSTEM INSPECTION E.OI(AI `A KT C SYS•I BI INFORAIATION(cuntil►ucd) ProptrlyAddress; 160 Marstons Avenue #1 yanni Owntr: Tim Fuller 1)aItoffotpe_El lon: e=,; 2 _"I- T1G1IT er IIOLUING ANK:_(tartk must be pulllpcd at time of insliectiou)(lucate un site plan) Dcpth below trade: hialcrial of coastfuc on:__conctcic_Instal_fibctglass_Iluiycthylcnc othct(cxplain): Uiuunsions: Coltacity: _gatluns Design flow; gallunstday Alarm present( cs or no): Alarm level. Alarm in wwking urdct(yes or uu). Date of last pumping: Cununcllls(condition of alarl!l and float switches.ctc_): DISTRIBUTION DOX; � f pttscnt must be olleneJ)(locate oil site plan) Dcplh of liquid level above outlet invell: Conunetits(note if box is level and disuibution to outlets equal,any evidence of solids ca,Fyover.any evidence of leakage into or out of box.ctc.): E l� PUNIP CIIAMBLIt•__(lucalc oil site plan) Pumps in woMn order(ycs or Ito): Alarms in►vulki g order(yes or no): _ Coltnncnts(no c condition of punels iftaltlllel,unldntun of palnps and al'IMIeltances,etc.): r f• -- r Page 9 of l; OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Avenue #� Hyannisport Owner. Tim Fuller Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why; Type _ ching pits,number_ leaching chambers,number: leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovativetaltemative system Typeiname of technology. Comments(note condition of sail,signs of hydraulic failure,level of pending,damp soil,condition of vegetation, etc_). _ c CESSPOOLS:/r. spool must be pumped as part of inspection)(locate on site plan) Number and con: Depth—top of let invert_ Depth of solids Depth of scum Dimensions of Materials of co Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials o construction: Dimensio : Depth of lids: Comme (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 1 � Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- 160 Marstons Avenue #1 Hyannisport Owner: Tim Fuller 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.Lute where public water supply enters the building_ � I Olt J + 1-2 1< 10 f -- Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: 160 marstons Avenue #1 yannispor. Owner. Tim u er Date of Inspection: r Y-- 6 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobservation hole within ISO 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: 47 I1 Town of Barnstable OF 1HE tp� Regulatory Services STABLE Thomas F. Geiler, Director ••� Public Health Division AtfD��A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. ,ate — ' CONDION'«EALTH OF MASSACHL;SETTS E%ECLTIx� OFFICE OF E1'VIRO\:1iE\TAL AFF_AJRS ,:_ F _ DEPARTMENT OF ENVIRONMENTAL PROTECTION O\�1tZ\=R STREET.BOSTON N1A 0210c (61:r 292-551it, TRi•DY COL:. Secre:ar.. ARGEO PALL CELLLCCI DAVID B STP;-'HS Governo- Commtss:one- SUBSURFACE SEWAGE DISPOSAL SYSTEM wSPECTION FORM PART A / CERTFICATION P,op,QA bor Village NantaofOwner. Lauralie Currier ' 160 MarstQns Ave, Hyannis AddressofOwner: Date of inspection: / `oZ 'Y—&'v Name of Inspector:(Please Prim Wltl. E e Robinson Sr. I am a DEP approved s eM inspector to Section 15.340 of Title S(310 CMR 15.000) Company; Wm. E . Robinson Septlic Service Mailing Address: PO BOX 0 9, C e nt ery i 11 e NLA 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 inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Inspector's Signature: Date: —L)—v The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to fire system owner and copies sent to the buyer. if applicable, and the approving authority. NOTES AND COMMENTS RED EC 1 � OCT 2 0 2000 KALT,DEFT, a reti �.se6 9/2/9E Pape iorn ati �: --ted o^Reo-cord Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART A CERTIFICATION (wrttinued) Nap"Address:#1 Harbor Village, 160 Marstons Ave. , Hyannis Jwner: Data of k4",� e r INSPECTION SUMMARY: Check( , H, C, o/ D: A. SYSTEM PASSES: ��//J 1 have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COM S: a. SYS CONDITIONALLY PASSES: On or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system. upon cc pletion of the replacement or repair.as approved by the Board of Health,will pass. Indicate yes, rio. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank, whether or not metal,is cracked,structurally unsound.shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup 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 Iwith approval of the Board of Health). broken pipe(s)are 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 revised- 5/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Iconbmmd) Property Address: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owrw: Currier Date of Inspection: 9.�/,,.t C. RTHER 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 ublic health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A CERTIFICATION Icorrtinued) Property Address: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owrw: CVrrier Date of Ins on: P'7";L/" D. SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faiiure. Yes N Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 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 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. 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. LARG SYSTEM FAILS: You must i dicate either "Yes' or "No' to each of the following: T e following criteria apply to large systems in addition to the criteria above: T system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public h Ith and safety and the environment because one or more of the following conditions exist: Yes o 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 11 of a public water supply well) The owner r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of th Department for further information. revlse6 5/2/5E PeRc.4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. - PART C SYSTEM INFORMATION 'rop"Address: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owner: Currier Date of Inspection: FLOW CONDITIONS RESIDENTIAL: ��11 Design flow:=6b.p.d./bedroom. Number of bedrooms(design): Number of bedrooms lactual): Total DESIGN flow $ 5'6 Number of current residents:_,/A Garbage grinder lyes or no):=,o Laundry Iseparate system) lyes or no);"; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):�(� Water meter readings, if ailable (last two year's usage(gpd): 6 svt H/f Ij Sump Pump (yes or no): /L Lest date of occupancy: / COM RCIALANDUSTRIAL: Type of tablishment: Design fl w: qpd 1 Based on 15.203) Basis of d sign flow Grease tr p present: (yes or no)_ Industri Waste Holding Tank present: (yes or no)_ Non•san tart' waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and o9 '27 inform/i � L Q 1 r7 1 System pumped as part of inspection. (yes or no)� U` f U I If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic lank idistribution boxisoil absorption system Single cesspool verflow cesspool /10 Privy Shared system (yes or no) (if yes, attach previous inspection records;if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other p APPROXIMATE AGE of all components, date installed(if known) and source of information: /7 - Sewage odors detected when arriving at the site: (yes or no)A/ U rev seQ Page 6 of 11 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Prop"Address: #1. Harbor Village, 160 Marstons Ave. , Hyannis owner: Currier Date of Inspection: 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No. Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and•the system has been receiving"arrmal 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. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.N. r/ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) _ The facility owner (and occupants,if differeru from owner) were provided with information on the proper.maintenaaca.of Subsurface Disposal Systems. rev_- seC 9j2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorrtimbed) lropeMAddress: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owner: Currier Date of Inspection: S„A *--'J BUILDIN SEWER: (Locate on ite plan) Depth belo grade:_ Material of c nstruet'on:_cast iron_40 PVC_other(explain) Distance fro private water supply well or suction line Diameter Comments- (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) � Depth below grade: 3 0�on.rete Material of construction: _metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_ (Yes/No) Dimensions: L 4,- G J Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: y Scum thickness: I —.2- G e Distance from top of scum to top of outlet tee or baffle: O Distance from bottom of scum to bottom outlet to baffle: / How dimensions were determined: 'omments: (recommendation for pumping�co7ditton of inlet and outlet tees or baffle , depth of I' level in relation to outlet invert, structurel integrity, evidence of leakage, etc.) �- �� ► -� �^- C, GREA TRAP: (locate o site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions Scum thick ess: Distance fr m top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of I t pumping: Commen s: (recom dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence o leakage. etc.) 5/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) +ropertyAddress: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owner: Currier Date of Inspection: 'n OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (Iota on site plan) Depth below grade:_ Meter al of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplein) Dimen ions: Capac ty: gallons Desig flow: gallons!day Alar present Alar level: Alarm in working order: Yes_ No_ Dat of previous pumping: Cc ments: (c n ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: tJ Comments: Inote if level and distribution is equalid ce of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate n site plan) Pumps working order: (Yes or No) Alarms in working order (Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances,etc.) revises 5/2 /9c Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirated) 'rop"Address: #1 Harbor Village, 160 Marstons Ave. , Hyannis Owrw: Currier Date of Inspection: %; SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:�I__ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding. damp soil, condi ion of v getaY n, etc.) CESSI OOLS:_ (locate n site planl Number nd configuration: Depth top of liquid to inlet invert: Depth of lids layer: )epth of s um layer: Dimension of cesspool: Materials o construction: Indication cf groundwater: inflow (cesspool must be pumped as part of inspection) Commen Incite co dition 7s6il, gns of hydraulic failure. level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials f construction: Depth of s lids: Dimensions: Comment : (note con ition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ' `_ G _c _ %L; Pig( 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) NopertyAddress: #1 Harbor Village, 160 Marstons Ave. , Hyannis 1M/1er: Currier Date of Inspection: G • SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I Al / 1 `V 10 ?Ole Pagc 10 of 11 r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icon*wW) ropenyAd*"s: #1 Harbor Village, 160 Marstons Ave.Hyannis Owner: Date of gmpectior'.U r r i e r NRCS Report name Soil Type_ Typical depth to groundwater uSGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property,observation hole. basement sump etc.) Determined from local conditions V Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revise' 9/21/96 Page 11of11 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION. jk _ 3 J DEL 2 b 2002 TOWN Or !jh v i ABLE HEALTH UEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION Z- Property Address: 160 Marstons Ave 3- . v NIT 3 Hyannisport ' Owner's Name: Arthur Fleitman Owner's Address: 3 Greenbriar Dr #307 N. Reading MA Date of Inspection: / /`f y 'a-- . .MAP PA ' _� c Name of Inspector:(please print) Wi 1 1 i am — Robinson Sr. LOT V N )� _3_ CompanyNa me: . William E. Robinson Septic Service Mailing Address: P 0, Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and.that the information reported, below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the.proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector,pursuant to Section 15340 of Title 5(310 CMR 15.000 The system: Passes , Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Zu e'Tk 1( ,,. Date: -0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaA—or' DEP)within 30 days of completing this inspection.If the system is a shared system or bas 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 approx. ing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPpOSA ART AYSTEM INSPECTION FORM CERTIFICATION (continued) 160 Marst Address' Property Hyannisport Owner. Arthur Fh itman Date of Inspection: Inspection Summary:::Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: I have not found any information which indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: " B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"...section.need to be replaced or letion of the replacement or repair,as approved by the.Board of Health,will pass: repaired.The system,upon comp P N in the for the following statements.if"not determined"please Answer yes,no or not determined(YND, ) explain.I 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 g that the tank is less than 20 years old is available. P a'm: ND explain: lObservation of sewage backup or break out or high static water level in the distribution box due Wbroken or o�cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced Me l The system required pumping more than 4 thnes a year due to broken or obstructed P4 s) The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obswctkm 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: 1 rQ Marst v nons Ave— 3 .. -.. Sport Owner: Armo r- R—1 eitman Date of Inspection: �f Y1-� 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 ism g to protect public.health,.safety or the environment. 1. System will pass unless Board of Health determines in accordance with110 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 1 Cesspool or.privy is within SO: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 syst Zm 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. LThe 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a of private water supply well".Method used to determine distance ,-`\**This system passes if the well water analysis,performed at DEP certified laboratory,for coliform ✓ bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. A he 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: n 3 Page 4 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F .'PART A CERTIFICATION(continued) Property Address: ve #3 _....... __ .. ... . ... . _ , Owner: ei man Date of inspect ion: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No ; _ due to over or clogged SAS or cesspool Backup of sewage into facility or system component _ 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 a less than'/:day flow s in the last year NOT due to clogged or obstructed pipe(s).Number Required pumping more than 4 time of times pumped Any portion of the.SAS,cesspool or privy is below high ground water elevation. I Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface i water supply. I 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 pnvate water supply well I Any portion of a cesspool or privy is less than 160 feet but greaterthan 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence"of ammonia equal to or less than 5 ppm,provided that no other failure criteria nitrogen and nitrate nitrogen is are triggered.A copy of the analysis must be attached to this form.] I (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 h Health to determine what will be necessary to correct the failure. E.�Large Systems: o[10,000 gpd to 15,000 To be considered a large system the system must serve.a.facility with a design flow gpd� You mu st indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no Lthe system is within 400 feet of a surface drinking water supply _ I 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 yo jhave answered"yes"to any question in Section E the.system is considered a significant threat,or answered ..yes," es"in Section D above the large system bay fai'kd.The owner or operator of arty large system considered a y significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 C MR 1 S. 04.The system owner should contact the appropriate regional office of the Department. 4 y Page 5 of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 -Marstons Ave #3 Hyannisport Owner: Arthur Fleitman Date of Inspection: 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, 1/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 r/ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) . Was the facility or dwelling inspected for signs of sewage back up? . Was`fhe site inspected for signs of break out Were all system components,excluding the SAS,located on site? V _ 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? L 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)) 5 • - f Page 6 of l l OFFICIAL INSPECTION FORM NOT FORVOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPO SAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 160 Marstons Ave . #3 Property Address: - Owner: - H!t7r - ---------- Date of Inspection:_j FLOW CONDITIONS RESIDENTIAL. .... _.. Number of bedrooms(design): Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):/Z � C� Number of current residents: ) Does residence have a garbage grinder(yes or no):/--.( Is laundry on a separate sewage system(yes or no):)! C) [if yes separate inspection required] Laundry system inspected(yes or no): � Seasonal use:(yes or no): :S Water meter readings,if available(last 2 years usage(gpd)): n/a ` shared water Sump pump(yes or no): A-;��,'� Last date of occupancy:: COMrIERCIAL(INDUSTRIAL ' Type ofestablishment: Design flow(based on 310 CMR 15.203): 'jpd Basis of esign flow(seats/persons/sqft,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 in ter readings,if available: Last date of occupancy/use: OTHER(describe): I . GENERAL INFORMATION Pumping Records Source of information: /5 q r 0 Was system pumped as part of the inspection(yes or no): ,�ua If yes,volume pumped:_gallons-=How was quantity pumped determined? Reason for pumping: TYPVOF SYSTEM LASeptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool E�?Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Altemative 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): Approximate age of all components,date installed(if known)and source of information: 0cj Were sewage odors detected when arriving at the site(yes or no): (� 6 Page 7 of 11 OFFICIAL INSPECTI,ON FORM-NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued).__, Property Address: 160 Marstons Ave #3 yannispor Owner: Arthur Fleitman Date of Inspection: BU$ DING SEWER(locate on site plan) Dep below grade: Mate als of construction:_cast iron 40 PVC_other(explain): Dista ce from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) 0 Depth below grade: �— Material of construction: t,concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance es or no (y ) _(attach a copy of certificate) p Dimensions: ;:;i 79' Sludge depth: Distance from top of ludge to bottom of outlet tee or baffle: 1; L Scum thickness: U1f Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffler How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): � �A Q e azr z,A,,-- . 4i.A7 GR SE TRAP:_(locate on site plan) Depth below grade:— Materi,i _ l of construction:_concrete_metal_fiberglass polyethylene_other.= (explain): Dimen tons: Scum t ickness: Distan�e from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): EA 7 page 9ofII OFFICIAL INSPECTION`FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons —Ave #3 yannisport— - _ - Owner: Arthur Fleitman Date of Inspection: TIGHT' r HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth bel w grade: - g _p Y Y Material o construction: concrete- metal fiberglass of eth lene other(expla'm): Dimensions": Capacity: Capaci Design Flog:_ gallons/day Alarm pre �ent(yes or no): Alarm in working order(yes or no): Alarm level: / g Date of last pumping: Commeitss(co dition of alarm and float switches,etc.): Z(ifresent must be o ened)(locate on site plan) DISTRIBUTION BOX P Depth of liquid level above outlet invert: Comments(note if box is level and distributio to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP HAMBER: (locate on site plan) Pumps is working order(yes or no): Alarms in working order(yes or no): ition of pumps and appurtenances,etc.): Conan�is(note condition of pump chamber,cond d - 8 r Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Mars tons Ave #3 Hyannispor Owner: Arthur Fleitman Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):Zoocate on site plan,excavation"not required) If SAS not located explain why: Type leaching pits,number:4Z " leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system .Type/name of technology: Comments(note condition of soil,sighs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): 1-6--6,-c) CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a'd configuration: Depth—to of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of'construction. Indication ofigroundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials oflconstruction: Dimensions- Depth of solids: Commen sl(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): /A 9 Page 10 of I] , 0 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTpRy ASSES SUBS SYSTEM INSPECTION SEWAGE DISPOSAL SYST ' SRM PART C, FORM SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #3 Ya Owner: Ar n Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. w' 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #3 yannispor Owner- Arthur ei man Date of Inspection: ,i 2- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _jZChecked with local Board of Health-explain: Checked with local excavators,installers-(attacdocumentation) Accessed USGS database-explain: You must descri a how you established the high ground water elevation: M 11 COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL a > DEPARTMENT OF ENVIRONMEN AI i `-�q ONE WINTER STREET, BOSTON. MA 02108 6 7-292-5500 y JUL 2 5 1997 ® MA R's�� HEALTE U-PT ' WILLIAM F.WELD TOWN OF CAE TRUDY CORE Governor � � ® s��m Secretary ARGEO PAUL CELLUCCI 6®, DAVID B.STRUHS Lt.Governor SUBSURFA SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A Harbor Villa � e CERTIFICATION Unit . 3 (St ley) Property Address: , 60 Ma o Ave, HyannisportAddress of Owner: Ellen Epro Date of Inspection: (If different) 32 Cushing St Name of Inspector: Wm E Robinson Sr Stoughton, MA 02072 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Sr Septic Sry Mailing Address: PO Box 1089 , Centerville, MA 02632 Telephone Numbeij. Q g—7 7 5—A 7 7 6 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewwaa e disposal systems. The.system: !/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Aa Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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: Check A, B, C, or D: Aj SYSTEM ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: Bj S STEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (ravixad 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Mnvw.magnet.state.ma.us/dep j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Harbor_Village PART A CERTIFICATION (continued) Unitw4,#3 .(,Studley) Property Address: 160 Marstons Ave, Hyannisport Owner: E11,en....E ro Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup 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). Describe observations: broken pipe(s) are 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] F RTHER 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 ora salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. N` The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Pago 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Harbor VVillage Unit #3 (Studley) Property Address:A0 Marstons Ave, Hyannisport- Owner: Ellen Epro Date of Inspection: 7 '7 D) SYSTEM FAILS: must indicate eit!:er "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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 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. 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: You rn/ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program regl irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Harbor Village Unit #3 (Studley) ` Property Address:160 Marstons Ave, Hyannisport Owner: Ellen Epro Date of Inspection: 7^A S- 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No i �3 _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least 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. S _ The facility or dwelling was inspected for signs of sewage back-up. �)e _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: aVvS _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. T Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (zavimad 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Harbor Village Unit #3 ( Studley) Property Address:/60 Marstons Ave, Hyannisport t Owner: Ellen Epro Date of Inspection: 7-1_r q 7 FLOW CONDITIONS RESIDENTIAL: Design flow: .p.d./bedroom for S.A.S. Number of bedrooms:_,!�—4 Number of current residents: Garbage grinder (yes or no): C Laundry connected to system(yes or no)X--6 Seasonal use (yes or no): -J-J Water meter readings, if available (last two (2) year usage (gpd): e a j e l a>2 Sump Pump (yes or no): A. v Last date of occupancy: —/.5—q r7 COMMERCIAUI N DUSTRIAL: Type of establishment: Design flow: Gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: C-- /,-'d /—ij0/ Vim��i System pumped as part of inspect on: (yes or n )_ If yes, volume pumped: Gallons Reasdn for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool ,Privy (/ Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? a j Other A -I V3 Q APPROXIMATE AGE of all components, date installed (if known) and source of information: /U --1 a-- Sewage odors detected when arriving at the site: (yes or no)A v (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Harbor Village Unit #3 (Studley) Property Address: 160 Marstons-;Ave, Hyannsiport Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) i Depth below grade: Ie Material of construction! cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) / I SEPTIC TANK: (locate on site plan) Depth below grade: /1� Y / Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age._ Is age confirmed by Certificate of Compliance _(Yes/No) t , Dimensions: t- W,c�6u Sludge depth: 'Y-4 Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness:_ , ! Distance from top of scum to top of outlet tee or baffle:_ `"' e Distance from bottom of scum to bottom of outlet tee or baffle: Z_ How dimensions were determined: w ►A Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles depth of liquid level in relation to outled invert, structural integrity, evidence of leakage, etc.), A f GRE E TRAP: (locate n site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensio s: Scum thi ness Distance rom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommelndation 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.) rv' (revimad 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Harbor Village Unit #3 ( studley) Property Address: 160 Marstons Ave, Hyann3sport Owner: Ellen Epro Date of Inspection: TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (I(ta on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimens ons: Capaci gallons Desi flow: gallons/day Alarm vel: Alarm in working order_Yes; _ No Date of �revious pumping: Commenits: (conditi o of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 6 PUMP C AMBER:_ (locate site plan) Pumps in working order: (Yes or No) Alarms i working order (Yes or No) Comments: (note corhdition of pump chamber, condition of pumps and appurtenances, etc.) LI V� (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Harbor Village Unit #3 (Studley) Property Address: 160 Marstons Ave, Hyannisport Owner: Ellen Epro Date of Inspection: ;?- ) S.- 1 '7 SOIL ABSORPTION SYSTEM (SAS): (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: Alternative system: Name of Technology: Comments: (note condition of soil,Jgns of hydraulic failure, level of ponding, condition of vegetation, et '1611- CES OOlS: _ (locat on site plan) Numb r and configuration: Depth-op of liquid to inlet invert: Depth f solids layer: Depth of scum layer: Dimensions of cesspool: Mate Is of construction: Ind s on of groundwater: ir..flow (cesspool must be pumped as part of inspection) Commen�s: (note con,l ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate oft site plan) Material's Dimensions: of construction: Depth of solids- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) J (revised 04/25/97) Page 8 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Harbor Village Unit #3 INFORMATION Property Address: 1,60 Marstons Ave, Hyannis ;port Owner: Ellen Epro Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) e0 11 { 1 r c \ (revised 04/25/97) Page 9 of 20 �w - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Harbor Village Unit #3 ( studley) Property Address: 60 Marstons Ave, Hyannisport Owner: Ellen Epro Date of Inspection: 7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions _ZCheck with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe, in your own words how you established the High Groundwater Elevation. (Must be completed) r _f t (revised 04/25/97) Page 10 of 10 LA2.' un_r s.-Marstan ;avenue ; s P``, 8uq Y' .n r r e!(.(I• fa S:r.G�+,n,' , r/xt .il ffl"1 r. p• F ! 4�. k%: c . AC`° ..Ir• L , rY U .,i" pr , ,riYy dill,� dv Y )Ar a it �f` X W 4 n y f ►y � t , ' °,ar '° p .:W '� .� � r� r? �n•,.� e dM ' b ' '^ a;3 '`�, 'Y f� f r �:, u ` ° "::r, i4 v ..4p C r y r� .. ^,4 �, �. br' ! ` '�. u ,r .ran G `u 7,• n.i} r "v_, `,gyp i �i:' r, ... e r A " If.:3 41.1 u o n ;16it , , r ,.� r F � rr o ry. r K ^r r r• w r It ,il o r u w:�r ,f. .'� ,,.r n r ... m ., Sa . .p �v ,�u .. B• .` rt' ,i .. ;,r .... � .. `i-. ,� u r I , r ..� n.r +,p r I`°.., .,� . f f Y .rU •.. w 4:, r'r !,. � •O r IrF ,. �••, ° ' � ' � .. " ry .� fo it n ,7 w , 2 tf f' „ .. , q.., rru �.� t:• . TM ,. ' n LA,x 1 r r' !1 �r r .�9 •,.. tj r n � ,r `'.❑ r A, F. S r,�.t _ r , f.. l r .., ..u° Fy, :; n ., . _ n "•U � , ri , ' : � b T'6 .r x ,. W r�.: .rl, d,r" ✓, n t n p r v in Lr q a po n i 'A „ r, rr N (} q n & R T F a I to pio it c If 10 ' q a L a - o p rh Sv r o Y d, k rzr r r r� �' r"g fir• n - o R .}eln. n r,ti /f r' Y:i r ry c [ 1 rn ij n " . r x a +�"^k+'4r••-^ -•vr',hr!*'k • ..,r.+•.c+' Yr'+..•.•, .-- .'�^.�'r.r+/i', ....,..._..._.'^-YqF.aa"`,.""!2+,'.&;...,.r,.,_�,,.._�....:..,,��s�.'�'P..:� t Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones _�Jl 0!-"-TAT$ Otl�/1 use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmaii.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority M'. b C CIO trJ 5/28/2013 " ( � Inspector's Signature Date L6 The system inspector shall submit a copy of this inspection report to the Approving Authority(oard of Health or DEP)within 30 days of completing this inspection. If the system is a shared', ysteW►-or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Lo 1U a3 t5ins•3/13 Title 5 Official InspWorm: rface Sewage Disposal System.Page 1 of 17 0 \'Dve SO Town of Barnstable Barnstable . Regulatory Services Department �mmicacfi 1 i + BABNSPABLF, 9 MASS. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0639 March 28, 2013 ALBERT &LINDA KURINSKAS, TRS. KURINSKAS (BARNS)NOMINEE TRUST 18 MILL POND ROAD IMPORTANT NOTICE WEST BRIDGEWATER, MA 02379 Map &Parcel: 288- 180 CO3 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. qPERORDER OF THE B ARD OF HEALTHas A.McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. Q:ISEWER connecALetters Stewart Creek Sewer COnnectsVAAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 _ page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 160 Marstons Ave Hyannis is served by a shared Title V septic system consisting of a 2000 gallon septic tank, distribution box and 4 leach pits. Although the system was found to be in proper working condition at the time of inspection this property has been ordered to connect to town sewer on or before 3/30/2015. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N 0 ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M (a 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 d- ❑ ® Y � � Y � �N 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner provided with ) ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil stem Absorption S A p y (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): 10 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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.) El Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: 6 Sump pump? ❑ Yes ® No Last date of occupancy: seasonalDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Ave Unit 4 G„ Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. CitylFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 4 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: 2000 gallons Sludge depth: 61' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown 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 3" W Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 is cleaned yearly Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 Marston Ave Unit 4 Property Address P KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 Marston Ave Unit 4 4M Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 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 0il 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.): I I 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.): I * If pumps.or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 4 ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M y 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C& LINDA A TRS Owner Owner's Name information is required for every Hyannis Ma 02601 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Ave Unit 4 Property Address KURINSKAS, ALBERT C & LINDA A TRS Owner Owner's Name information is Hyannis Ma 02601 5/28/2013 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 K .,_ COI2%10. WEALTH OF MASSACHLSETTS _ ExECUTWE OFFICE OF ENVIRONMENTAL AFF:AIP.5, = = F DEPARTMENT OF ENVIRONMENTAL PROTECTION O\E WINTER STREET. BOSTON UA 0210t 1617i 292-550v TRL DY COIE Secre;a-- ARGEO PALL CELLUCCI f DAVID B STR'-'HS Governor Comlussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Harbor Village Condos CERTIFICATION Prop"Add►ess: 160 Marston Ave .UnitNI 5 _ Nameofowner Paul Sullivan Hyannisport Amass of owner: Date of Inspection: Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerq inspector rsuant to Section 15.340 of T-rde 5(310 CMR 15.000) Company Name: Wm• E . Robinson eptic Service Mailing Address: PO Box 0 9, Centerville .--MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se a disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 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. NOTES AND COMMENTS '044.oF 41000 , revised. 5��9� Pegv Iof11 i� !,-red on Reazlyd Panr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'a PART A CERTIFICATION(continued) 'roperty Address: 160 Marston Ave . , Hvannisport Unit 5 Owner: Paul Sullivan Date of Inspection: INSPECTION SUMMARY: Check �)8, C, o/ D: A. 77— PASSES: ve not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system. upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicat yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup 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 Iwith approval'of the Board of Health). broken pipe(s) are 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION Icorrtinued) Property Address: 160 Marston Ave . , Hyannis-port Unit 5 ` owner: Paul Sullivan Date of Inspection: 6 7- D. SYSTEM FAILS: You st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No Backup of sewage into facility-or system component due to an overloaded orclogged 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 1/2 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 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 private water supply well. ti i 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. LA RGE SYSTEM FAILS: You me st indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: 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) The wner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offi of the Department for further information. r elk— revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (cortfinued) Property Address: 160 Marston Ave .. , Hyannis-port Unit 5 Owner: Paul Sullivan , Date of Inspection: C. RTHER 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) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revise--3 Page 3of11 Y .r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 160 Mrst`on Ave . , H.yannisport Unit 5 Owner:, , Pau.l Sullivan Daie of.Inspection:G Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No ✓ _ Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system components have been pumped for at least 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. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓/ _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.N. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1.5.302(3)(b)) The facility owner(and occupants,if different from owner) were provided with information on the Propermaintenamro-0f SubSurface Disposal Systems. re�v.Lsen 9i 2/98 Page sar`I, 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address:1.60 Marston Ave . , Hyahnisport Unit 5 Owner: Paul Sullivan Date of Inspection: . FLOW CONDITIONS RESIDENTIAL: Design flow: (>g.p.d./bedr,00m. Number of bedrooms(designl:_i Number of bedrooms (actual):$ Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no):,40 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no)--4-LL''3 Water meter readings, if available (last two year's usage(gpd): Central water Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: C /L;e—A.-L -C Ve-,L System pumped as part of inspection: (yes or no)�Z b If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank'distribution box/soil absorption system Single cesspool Overflow cesspool Privy T c L Shared system (yes or no) (if es, attach $/ �r /V /d ,v'Oi Y Y previous inspection records:if any) �j Z I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: f 4. S—• Sewage odors detected when arriving at the site: (yes or no) O rev:Lsed 9/2/9E Page 6of11 I � >� 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roper'tY Address:160 Marston Ave . , Hyannisport Unit 5 owner: Paul Sullivan Date of Inspection: 4 _7-&--d BUILDING SEWER: (Locate on site.plan) Depth below grade: 1�` Material of construction:_cast iron_40 PVC_ other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,ek.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:Jz/.oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: '2-4 A 7 3 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle:i 1 Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 6 'omments: (recommendation for pumping, condition of inlet and outlet tees or be fles, depth off liquid level in relat2, e on tpp outlet invert, structural integrity, evidence of leakage, etc.) 3 ss-�1 ce/ h-l 2, c, 1i GREA E TRAP: (locate n site plan) Depth be ow grade:_ Material o construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimension Scum thic nest. Distance f m top of scum to top of outlet tee or baffle: e Distance f om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comme ts: (recom ndation 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.) rev» sc.0 9/2/96 Page 7of11 r � N • 3: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) 'roperty Address: 160 Marston Ave . , Hyannisport Units Owner: Paul -Sullivan Date of Inspection: TI OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloca on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass Polyethylene_other(explain) Dimens ons: Capacit gallons Design ow: gallons/day Alarm resent Alarm vel: Alarm in working order: Yes_ No_ Date previous pumping: Com ents: (co ition of inlet tee, condition of alarm and float switches, etc.) / 4 DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evide nZ of solids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order(Yes or No) Comme ts: (note c ndition of pump chamber, condition of pumps and appurtenances,etc.) reVlse6 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) top"Address: 160 Marston Ave . , HVannisport Owner: Paul Sullivan Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_✓ llocate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits', number:_ leaching chambers,number:/ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic fail u , level of ponding, damp soil, condition of vegetation, etc.) / S b!, G l IY '3 1 C SPOOLS:_ (Iota a on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: 7epth o solids layer: )epth of cum layer: Dimensio s of cesspool. Materials f construction: Indication f groundwater: i flow (cesspool must be pumped as part of inspection) Comments (note cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate site plan) Meter' Is of construction: Dimensions: Depth f solids: Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 4_ ' e ,1 s e•• _9/L ir.7� Pair 9 of l l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '1-roperty Address: 160 Marston Ave . , Hyannisport Unit 5 .)Wrw: Paul Sullivan Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) v u men L 7 revised 9/2/9? Page 10of11 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .� PART C SYSTEM INFORMATION(caftnued) ►OPertyAdd►ess: 160 Marston Ave . , Hyannisport Unit 5 Owner: Paul Sullivan Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater ------------- USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells J Estimated Depth to Groundwater L� Feet Please indicate all the methods used to determine High Groundwater Elevation: • /Obtained from Design Plans on record t/ Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (M ust be completed) l0 t -evisec 9/2/.5 M Pagc.11 of 11 ' I I CON ' DATE:_7L2-9/.99____ PROPERTY ADDRESS:2_7_2__Cr_a_iville_Beach—Road Unit #5 West—Hyannisport ,Mass_ ----- 6 70-7 3�oF On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1-2000 gallon septic tank. 2 . 1—Distribution box . 3 . 5-1000 gallon precast leaching pits . Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time . 6 . This is a shared system. Units 1-5 & 11-15 share thisseptic system. 7 . Tank cover s at the surface . 8 . Tanks should be pumped annually . Garbage disposals are present . - SIGNATURE: 1 Name:_,L _ Macomber JJr-___—__ Company: Josevh_P_ Macomber_& Son , Inc . 00 �. V Address:_ ox B _66_____________ , AUC —_ e 2 3 .l,gg9 W:y Centerville , Ma . 02632-0066 �- ------------ e.`� N pNSM8L f fPT Phone:___508_775=3338_______ p THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS t r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVMON2r1ENTAL PROTECTION 1Vj ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX Secrete. ARCEO PAUL CELLUCCI pAv?D B. gTa L i Corr:.ss:oc Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION 272 Craigville Beach Road Name of owner Louis Mass . Property A ddr es.e West Hyannisport ,Mass . Unit 5AddrassofOwnar: Dau of 4upec-don: Name of inspector:(Please Prim) Joseph P. Macomber Jr. I am a DEP approved systam Irupector pursuarrt to Section 15.340 of This 6 (310 CMR 15.00o) CornparsyNartse: Joseph P. Macomber & Son, Inc. M&Mng Address: 2632-0066 TeJ&phone Number. 5(I��8 CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at We address and that the Information reported below is true. sccurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further E aluation By the Local ppfoving Authority _ Fails inspector's Signature?h&II Date: The System Inspectosubmit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whnin tnirty (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 own#, small submit the report to the appropriate regional office of the Department of*Envkonmerual Protection. The original should be sent to Zrse system owner•and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Peet1of11 C' Prmtrd on 0.ecycbd Pipet SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION (continued) Prope<cyAddres:: 272 Craigville Beach Road West Hyannisport ,Mass . Unit #5 Owner: Louis Mass . Date of Inspection: 7/2 9/9 9 INSPECTION SUMMARY: Check A, B, C, or A A., SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are Indicated below. coMMENTs:This is a shared system. Units 1-5 & 11-15 share the e`me ,S'ept i r c3retam B. SYSTEM CONDITIONALLY PASSES: '_ 12+ 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. Indicate yes, no, 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,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe($) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipes)are replaced obstruction Is removed distribution box is levelled or replaced - The system required pumphig-more than-four-dmes ayeardue to broken or obstructed pipe(s). The system wHtvasr-- Inspection if(with approval of the Board of Health): - broken plpe(s) are replaced obstruction is removed " o revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 272 Craig.ville Beach Road West Hyannisport ,Mass . Unit #5 Owner: Louis Mass . Date of Inspection: 7/2 9/9 9 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE E0W80NMENT1 4V Cesspool or privy is within 50 feet-of surface water AD Cesspool or privy is within 60 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 AND SAFETY AND THE ENVIR0NMENT: 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance�—(approximation not valid). 3) OTHER s revised 9/2/98 Page 3or11 �. . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corttirwed) Prop,&MAddre": 272 Craigville V ach Road West Hyannisport ,Mass . Unit #5 Owrw: Louis Mass Dina of Irupection: 7/2 9/9 9 D. SYSTEM FAILS: You must Indicate either 'Yes' or 'No' to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes Now Backup ofrewage irno iaci6"r-arTatem component•duetto m overloaded orcbgged•SAS•orKesspool. 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 a distrl Hon box abo outlet invert due to an overloaded or clogged SAS or cesspool. Uq AM r t;- Liquid depth in ess.pevl Is less than 6' below Invert or available volume Is less than 112 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ZAny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. x/ 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 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 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 lot colilorm bacteria, volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either 'Yes' or 'No' to each of the following: The following criteria apply to large systems In addition to the criteria above: . The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant throat to puolit health and safety and the environment because one or more of the following conditions exist: Yes No ' the system Is within 400 lest of a surface drinking water supply !r the system•Is-within 200 I"tol e-tributary-(o a cu1faoo'-d14nk:ag-w6tw-4uPPIY -- the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area -IWPA) or a mapped Zone II of a puoi.c water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department lot funher Information. 4 revised 9/2/98 Peee4of11 f I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B fa CHECKLIST PropertyAddre":272 Craigville Beach' Road West Hyannisport ,Mass . Unit #5 Owner: Louis Mass . Date of Inspection: 7/2 9/9 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No,, Pumping information was provided by the owner, occupant, or Board of Health. None of the system•cornpooants haMebesn pwnped4orzatJeast-two aweelwsad�dwwystam hasbaeowceiaiwgaeo"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. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components,ea6cluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan at B.O.H. Y _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) The facility owner.(and.ocr pawts..if diffwaat from o ner),++iaraprcyided.wiih lnfouaation:nn th&4 rnpar^ Stan ar ^f SubSurface Disposal Systems. � s i 1 ( revised 9/2/98 Page 5of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION +' PropertyAddrwu: 272 Craigvil1ebeach. Road West Hyannisport ,Mass . Unit #5 Owner: Louis Mass . Do%@ of 4upection:7/2 9/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: 4# g.p.d./bedroom. Number of bedrooms(desi ) Number of bedrocoo s(actuaq:jA# 6� Total DESIGN flow. n dwr 7' s r� Number of current residents- Garbage grinder(yes or no): Laundry(separate system) or n�o It yes, sepacaL Inspection.required Laundry system Inspected ye or no) Seasonal use (yes or no): Water meter readings,If available (last two yesr's usage (gpd): j ,ter ms Sump Pump (yes or no): AV Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: A ppd ( Based on 1.203) Basis of design flow Grease trap present: (yes or no)jffl — Industrial Waste Holding Tank present: (yes or no)A Non-sanitary waste discharged to the Title 5 system: (yes or no)A)—/f Water motor readings,If available:__ Last date of occupancy: AJA OTHER:(Describe) � �— Last date of occupancy: GENERAL INFORMATION PUMPING RE RDS aA source of 1 rrnation: Sysj`eM-%P"umpa9 as part of inspection: (yes or no) If yes, volume pumped: ca!lons Reason for pumping: TYPE OF SYSTEM _,.�Septic tank/distribution box/soil absorption system & _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, a:iach previous Inspection records,If any) I/A Technology A}�, Attach copy of up to date oporatlon and maintenance contract un Tight Tank /?i�f _Copy of DEP Af proval Other —tI1LT._ --_ APP g�yMATE GE of a components, date installed{,,,kn wn)•and sowce.o(4oformation: SJ� 1YY6 0 f` AIJ r Sewage odors detected when arriving at the sate: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con-tinued) -,'Top--tYAdd1—: 272 Craigville Beach Road West Hyannisport ,Mass . Units °"'r'°r` Louis Mass . Dat, or inspection:7/2 9/9 9 BUILDING SEWER: (Locate on site plan) /f Depth below grader Material of construction:-, C.st Iron/0 PVC_other(explain) Distance from prlvete water supply well or auction line 14 If- Diameter. _ Comments: (condition of Joints, venting, evidence otlaakaga,-etc.) Join , S blMsc TAMK: (locate on site plan) Depth below grado: �loncret4lv&mst&WAFIbeiglassWAPolyethylenWAother(explain) Matorlal of construction: VA If tank Is inetal, list ape yy 14.age.confvmed by Certificate of Complfsnc (Yes/No) Dimensions: Sludge depth:,_ -. Distance from top sludge to bottom of outlet tea ortratfio.. Scum thickness: AXA t.L_ Distance from top of scum to top of outlet tee or beHle:�i Distance from bosom of scum to bono t of outi toe or baffle How dimonslons were determined: Comments: (recommendation for pumping, condition of Inlet and outJot tees or-baffles, depth of liquid lever In relation to outlet invert, suuctutft",teyrity - evidence of leakage, etc.) e sriows no evidence o leakage . GREASE TRAP: e- (locate on site plan) Depth below grado:Az Material of construction:49concretokdmolal41barglass/✓•�Polyethyleno otherlexploin) AIA Dimensions: Scum thickness: Distance from top of scum to top of outlet too or batflo:Ag Distance from bottom of s um to bonom of outlet tee or.battle:—#A Date of last pumping: Comments: (recommondation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, sLtucturaj integnn evidence of leakage, etc.) Grease revised 9/2/98 Paee7orit Macomber Customer History Screen 7129199 Customernumber 3163 Company Fame "" _ Create New lwoice p y ' Axa i..:. .�f. u ini.4.219:154.3.7.....---•.................................................. Customer Name _QQndQ.host..................................... 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P� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cortDrwed) PTope<tyAddr—:2.72 Craigville Beach Road West Hyannisport , Mass . Unit 5 o'Mfe( Louis Mass . Data of Irtspecrdon: 7/2 9/9 9 TIGHT OR HOLDING TANKAM (Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:} Material of constructionLN concrete/lqmetal4AFiberglass, /&Polyethylene4tother(explain) AM AN Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm In working order:Yes Noa[It Date of previous pumping:_ IVA _ Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) ilght or o inQ tanks are not pracpnt DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet Invert: Comments: (note-if level and distribution is equal, evidenoo of solids carryover, evidence of leakage Into or out of box, etc.) — — Distribution box has 9 1nteralg Un eAridenCP cif solid2 car Iw r-ynArpr it# 96-r- eet of the 187 PUMP CHAMBER:Aiiwe. (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.) 4 revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSALPART C SYSTEM INSPECTION FORM ' SYSTEM INFORMATION (continued) 1; .PropaMAd&9"'272 Craigville Beach Road West Hyannisport ,Mass . Unit 5 Owner Louis Mass . Dole of Inspection. 7/2 9/9 9 SOIL ABSORPTION SYSTEM(SAS):, roximated by non-Intrusive methods) (locate on site plan,if possible: excavation not required,location may be app If not located, explain: Type: leaching pits, number:, leaching chambers,number: leaching galleries,number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system:��4441i Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pondfng, damp soil, condition of vegetation,.etc. 4 ` / s o c ra�ui ai e a 1 n norm CESSPOOLS: (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: Materiels of construction: Indication of groundwater. inflow (cesspool must be pumped as part of Inspection) es Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of.vegetation, etc.) es PRivY•LV1//rTi (locate on site plan) Dimensions: IeA Materjal3 of constru tion: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation,etc.) riv .e Pace 9orll revised 9/2/98 f SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C , SYSTEM WFORmATION (con*ujad) • PropoMAd&—: 272 Crajgville Beach Road West Hyannisport Unit5 Ownte: Louis Mass D"a of tn+.p.cvon:7/2 9/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (locate where public water supply comes Into house) b Jb , r i revised 9/2/98 Poe�tootll r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM n PART C 7 SYSTEM INFORMATION(continued) Property Address: 272 Craigville Beach Road West Hyannisport ,Mass Unit # 5 DWrw: Louis Mass . Date of Inspection: 7/2 9/9 9 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells F Estimated Depth to Groundwatedb Got Please indicate all the methods used to determine High Groundwater Elevation: �btained from Design Plans on record bserved.Sita (Abutting property, bservation hole, basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Installed System 6/14/96 No water encountered at 14 ' revised 9/2/98 Page IIofII e 1�.nr�.-nT+•r-+-.� nraew•niswnrnnnna►.rn�.+w��nr.�.+.�nRwy nr�-:s��n ram+ ' , 1 TOWN OFBARNSTABLE WARD OF HEALTH r ^ SUI)SURFACF SEWAGE DISPOSAL .SYSTEM INSPECTION FORM - PART D .- uwrI FI C4TION �- �-•rn-�••.-:: -t.iin-.+ran•.rw.•r..w-.r�ir1ms.Trwn:�-n�-+�� rwsr-r'�w:vrR+ww.�n�-rT� nnnn�.rrs�.rs�•.rrn+m.+•.-,nrr•r-�. '-TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 272 Craigville Beach Road Unit # 5 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Louis Mast . PART D - CERTIFICATION -NAME OF INSPECTOR Joseph P. Macomber, Jr. COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 Street Town or City State t I P COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh or the environment as defined 'in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have cony-Lcted has found that the system fails to Protect the ptiblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD OF HEAL1'll. • If the inspection FAILED, the owner or" perator shall u within one year or' the date of the inspection, unless allowed dort required he m otherwise as provided in 3.10 CMR 16 , 306 . partd . doc COMMONWEALTH OF MA.SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® SEP 0 4 2003 TOWN OF BARNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 160 Marstons Ave Hyannisport ��"' Owner's Name: Jeff Mahan MAP Owner's Address: PARCEL ' Date of Inspection: �-2--,,.6 '2 SOT Name of Inspector:(please print) W i 11 i am E_ • Robinson, Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1 089 Centerville, MA - p . Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT + I certify that I have personally inspected the sewage disposal system at this address and that the information reported . below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system-inspector pursuant to 7asses ' n 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: L� V " ` Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Ma r s tnn g Ave #6 HYannisl2ort Owner: Jeff Mahan Date of Inspection: $ - '1-.:a 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S Item Passes: 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: C!'"�'"- � �� 7 AB. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla'1. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally torso d,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the exist' g tank is replaced with a complying septic tank as approved by the Board of Health. •A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ting that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app oval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in nection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rttmond 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: 160 Marstons Ave #6 Hyannisport Owner: Jeff Mahan Date of Inspection:_ cL'a-w'3 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 fai g to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2, Conditions will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syst m 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 urface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 frond 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: 3 Pagc 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Ave #6 Hyannisport Owner: Jeff Mahan Date of Inspection: D. System Failure Criteria applicable to all systems: Yo must indicate"ycs"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00,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 f^_et from a private Aatrr 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 (lie presence of ammonia nitrogen and'nitrale 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 forma es/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 considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 FPd• You m st indicate either"yes"or"no to each of the following: (The fo lowing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Z ne 11 of a public water supply well If you have swered"yes"to any question in Section E the system is considered a significant tlucat,or answered "yes'in Sec 'on D above the large system has failed.The vwner or operator of any large system considered a significant t eat under.Section E or failed corder Section D shall upgrade the system in accordance with 310 CMR 15.304.The ystem owner should contact the appropriate regional office of the Department. ` 4 f 1 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:-160 Marstons Ave 16 Hyannisport Owner: Jeff Mahan Date of Inspection: --e Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No / p/Pumping information was provided by the owner,occupant,or Board of Health _ _zWcre any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ =v Have large volumes of water been introduced to the system recently or as part of this inspection? t/= Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? (/ Was the site inspected for signs of break out? t0 _ 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)] I� 5 f Page 6 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Marstons Ave Hyannisport Owner: Jeff Mahan Date of Inspection: —3 -'FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): G Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Lf Number of current residents: 4 Does residence have a garbage grinder(yes or no):A0,O Is laundry on a separate sewage system(yes or no):oLO [if yes separate inspection required) Laundry system inspected(yes or no): 0 Seasonal use:(yes or no):)e�g-,$ Water meter readings,if available(last 2 years usage(gpd)): n/a common water Sump pump(yes or no): A—p Last date of occupancy: T-27—p 3 COMM CIAIANDUSTRIAL Type of es blishment: Design flo (based on 310 CIv1R 15.203): gpd Basis of des pi flow(seats/persons/sgft,etc.): Grease trap resent(yes or no): Industrial w to holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter eadings,if available: Last date of ccupancy/use: OTHER(de cribe): GENERAL INFORMATION Pumping Records Source of information: sr/C �- A ^A_ Was system pumped as p rt of the ins ection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPj OF SYSTEM _/Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy r _Shared system(yes or no)(if yes,attach'previous inspection records,if any) _Innovative/Altemative 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): Approximate age of all components ate installed(if known).and source of information: Were sewage odors detected when arriving at the site(yes or no):/t-U 6 I� 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: 1 h0 RMahstohsaA 76 #6 _ Hyannisport Owner: 7 -f f Mahan Date o(lnspecllon:_�-3.'1�-a BUILDING SE'VE (locate on site plan) Depth below grat/de of const ction:_cast iron 40 PVC_other(explain): Distance from pri ate water supply well or suction line: Comments(on c ndition of joints,venting,evidence of leakage,etc.): SEPTIC /(locate TAnK. on site plan) Depth below grade: 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) v , Dimensions: eg' 4 Sludge depth:_`y ' ' j J Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: 6 -1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee o� battle: l , How were dimensions determined. 16-r� �a L, Jx*r'. Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as relate. to outlet invert,evidence of leakage,etc.�:/ 0 C) i+n !� d %.. G GREASE T P:_(locate on site plan) Depth below de:_ Material of con truction:_concrete_metal_fiberglass_polyethylene other (explain): Dimension)(Onumping Scum thick Distance frof scum to top of outlet tee or baffle: Distance from of scum to bottom of outlet tee or battle: Date of lasng: Comments reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t invert,evidence of leakage,etc.): 7 Page 8 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Mar-,tons Ave HWannjspnrt Owner: Jt=ff Mahan Date of Inspection: TIGHT or HOLDING T (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: allons Design Flow: allons/day Alarm present(y or no): Alarm level: Alarm in working order(yes or no): Date of last pu ping: Comments(c ndition of alarm and float switches,etc.): DISTRIBUTION BOX: �(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBE (locate on site plan) Pumps in working der(yes or no): Alarms in working rder(yes or no): .Comments(note c dition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #6 Hyanni snort Owner: J Date of Inspection: rl-- SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,ezcavation'not required) If SAS not located explain why: Tin g ing pits,number: chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: inn ovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pondin;,damp soil,condition of vegetation, etc.): _`J 8 a _y r �� 5 i a �y �.� t- l�zf L- bo , CESSPOOL (cesspool must be pumped as part of inspection)(locate on site plan) Number and con guration: Depth—top of liq id to inlet invert: Depth of solids la r: Depth of scum lay Dimensions of cess ool: Materials of constn ction: Indication of group water inflow(yes or no): Comments(note co idition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (loc to on site plan) Materials of cons ction: Dimensions: Depth of solids: Comments(note ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Margt.nnG Ave HYann i s=nrt Owner: ,Toff Mahan Date of Inspection: 7-2L'7^0 3 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. I-Dy J a 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 hn Marct-nnc Avg Hyanni c;nrt- Owner. Jiff Mahan Date of Inspection: a - SITE EXAM Slope Surface water Check cellar. Shallow wells i Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: 06tained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how xxou established the high ground water elevation: 4'aw 3 7 ��la 1-� s ,0, 6 A, z_C.) 0C k1ha . ld 11 160,Unit-6Marston Avenue "-.- y 'T Hyannis.",P - My. AN_ 288 18000F. r Yj - rig a i .,,.. .-r.......--..--.^-�-..�,_�,,r�-•� ..+....a..^...,.- �:-.�.. .. ��-�..-,,.;.. ._�,,...,,.�,,.,.,,,....,_,,,.,,,..,,:m..-�-+...,. .r.-�..-,'_..««.-.._�.-,.•--^•.^"'r-.—. - .:--�,.-'--•-.-.. - .^^��.,.....�..+-.....,,- -..,wow,..-. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe Go»rnor gory Argeo Paul Celluccl David B.Struhs LL Gowmor Commfrbrnr / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION lly.9-�i r1�s for t 7 �I Property Address: Address of Owner. / fit✓ Date of Inspection: i.j.q —'I Cv (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 6<j e.1 ✓�-^'—�� Date: 1-1—g 9 tr The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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. INSP TION SUMMARY: Check B, C,or D: Al SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. failure criteria not evaluated are indicated below. Bl SYS CONDITIONALLY PASSES: ne or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes pection. Indica ,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain wby not) The septic tank is metal, cracked,structurally'unsound,shows substantial infiltration or exf3ltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. revised 11 03 95 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)M-5500 ice,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) /y Property Address: M�/'S✓(/!►.� ,/9U-- 08'lZi2d<S �Pr Owner. Date of Inspection: L1 B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution boa 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): broken pipe(s)are replaced obstruction is removed ` distribution box is levelled or replaced The system 2egrured pumping more than four times a year due to broken or obstructed pipe(a). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) FUR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the lic health,safety and the environment. 1) YSTEM 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 FUNCTIONING 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 within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply 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 ooliform 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 lass than 5 ppm. 3) OTH (revised 11/03/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: I Le O ry1f�/'S7�W,S, Owner. Jed r,61-11a /�-u Vn I�. Date of Inspection: ; (�_ 9 DI STEM 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 determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 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 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. 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. El LARGE YSTEM FAILS: following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public 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 supple' the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone H of a public water supply well) The owner or . for of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 3 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address I� 0 md9r s�lh s, Azle— Owner. Date of Inspeotim 41_ 9-� 4 Check if the following have been done: Zpumpilg information was requested of the owner,occupant,and Board of Health. Done of the system components have been pumped for at least 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. facility or dwelling was inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow V The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. _11rhe septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of m. �'1'he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _v The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11vo f7'14rS)lJ '-3 Owner. �� R U.O/91C11( Date of Inspection: FLOW CONDITIONS ENTIAL• Design w gallons Number bedrooms: Number o cur residents:_ Garbage (yes or no):_ _ Laundry to system(yes or no):_ Seasonal (yes or no):_ Water r readings,if available: Last date of occupancy: COMMERCIALANDUSTRIAL , / Type of establishment:_C n ! {rA r Ql- Design flow:1¢yr,0 pllozWday Grease trap present: (yes or no) 9' Industrial Waste Holding Tank present: (yes or no),&�G Non-aanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: C L� %O w•L Lest date of occupancy: �` ) 9 �► OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / /�'Pt- ) t 9 '3 / `Y ! 9 1 LCob ruse�,. Gr c System pumped as part of inspection: (yes or no)_A,,O If yea,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/sod absorption system Single cesspool rflow cesspool rivy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: /O /Y=S ®U Sewage odors detected when arriving at the site: (yea or no)_Z(l v (revised 11/03/95) 5 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)- Property Address: 1 Owner. �� -9 Q G Date of Inspection: <`_ 9 S SEPTIC TAN— (locate on site plan) Depth below grade:_ _ Material of construction: ncrete_metal_FRP—other(explain) 14 i µ- me Dimensions: G !.c/ f7'G —t L��C�" n Shrdge depth: �1 3 Distance from top of sludge to bottom of outlet tee or baffle:'_/F Scum thickness: O F Distance from top of scum to top of outlet tee or baffler_ Distance from bottom of scum to bottom of outlet tee or baffle:9 lh Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,de th of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) e IV a i a- /.a t GREAS - _ (locate on si plan) Depth below Material of natruction:_concrete_metal_FRP—other(explain) Dimensions: Scum Distance from p of scum to top of outlet tee or bade: Distance from m of scum to bottom of outlet tee or baffle: Comments: (recommends on for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of ,etc.) (revised 11/03/95) 6 f , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / flrS mains '9Ue-, 7 Date Owner. /7 Inspection: ® l 1 A(•{'�f'II Glt TI OR HOLDING TANK— ( on site plan) Depth grade: Material construction:_concrete_metal_FRP_other(explain) - Dime Capaci gallons Design flo gallons/day Alarm leve Comments: (coaditi0 of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX- (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if�level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) n-- (� oc� � Cam » cam • PUMPZinrking BER;_ (locateplan) Pumps order:(yes or no) Comm(note c of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addreex 6 /9 L y/�-'gnmio"5vl- Owner. � Date of Inspection: q SOIL ABSORPTION SYSTEM(SAS): (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: `'I 16 leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: Comment�sr�(note oonditi of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.) �/ .5 /, 0 st r cA / P ) O CIo tq °p-O CESSPOO (locate on site Ian) Number and oo tion: Depth-top of d to inlet invert: Depth of solids Ig yer: Depth of scum la r: Dimensions of pool: Materials of 00 on: Indication of water: inflow(cesspool must be pumped as part of inspection) Comments: (note ' ' n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site p Materials of co Dimensions: Depth of solids: Comments:(note co n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: to ng4r,5 r,)21, 14V'f- o�y /'I�S �✓� Owner. f 2,,on q-1,a A Date of Inspection: a`_9 — SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' .3 r TQc�vi�S AV G pe{c Y a- DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: r (revised 11/03/95) 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cl mown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in"any way. Please see completeness checklist at the end of the form. Imp°ft"t When filling out A. General Information — -- forms on the computer,use 1. Inspector: only the tab key ,. to moveyour I �`+' DOUGLAS A BROWN cursor-do not Name of Inspector use the return p key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cltylrown State Zip Code 508-420-4534 S14297 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 beldw 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 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/15/10 Inspector Ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•osoe Title 5 Official Inspection Form:Subsurface Sewage Disposal ern• e 1 f 7 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09108 Title 5 Offxial Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced '❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 a . Commonwealth of Massachusetts Amwm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cdyfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage asposai system•Page 4 of 17 Commonwealth of Massachu setts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 160 MARSTONS AVE UNIT 8 Properly Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Clty/Town State Zip Code Date of Inspection C..Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and 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): 9 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 990 t5ins•09A)8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cltyrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PREVIOUS INSPECTION REPORT SYSTEM IS A SHARED SYSTEM CONSISTING OF A 1500 GALLON TANK D-BOX AND TWO 6X10 LEACH PITS Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: NOT AVAILABLE AT TIME OF INSPECTION, COTTAGES ARE MOSTLY SEASONAL Sump pump? ❑ Yes ❑ No 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: t5ins•091D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA every page. Clty/Town State Zip Code Date of Date of 0 Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �r 160 MARSTONS AVE UNIT 8 I Property Address DEIANO Owner Owner's Name information is HYANNISPORT required for MA 7l15/10 . every page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: UNKNOWN Were sewage odors detected when arriving at the site? ❑ Yes N. No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ pol�eth lene Y y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Properly Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cityrrown 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 Scum thickness VARYING Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is required for HYANNISPORT MA 7/15/10 every page. iWr own State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09I08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•tea Title 5 Official Inspection Form:Subsurface Sewage asposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every 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 p eV t©JS l N' PCB toro I(Le w�- t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: OFF PREVIOUS INSP REPORT DATED 4/17/99 BY ROBINSON SEPTIC SERVICE Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09 D8 Title 5 Official Inspection Form:Subsurface Savage Disposal System•Page 16 of 17 Commonwealth of Massachusetts f R Wora-ffl- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 MARSTONS AVE UNIT 8 Property Address DELANO Owner Owner's Name information is HYANNISPORT required for MA 7/15/10 every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CO -MONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE 'WINTER STREET, BOSTON KA,0210S (617) 292-550li TRUDY CONE Secre-an ARGEO PAUL CELLUCCI DAVID B. STR HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addressi60 Marstons. Ave . #8 Name of Ow hirley Stamps Hyan t , MA Address of Owner:13 10 . ,Centerville Date of Inspection: P�q Name of Inspector:( e HirtRobinson Sr . I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson Septic Service Mailing address: P O Box 1089, C PntPry i 1 1 P , MA Telephone Number: _8!7!7(, 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails 100, inspector's Signature: P� ' g � � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 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. r NOTES AND COMMENTS y , 9 t� io AY TOWN OF SARNSTABLE HEALTH DEPT. revised 9/2/98 Page Iof11 i� 111"Id on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "rop"Address: 16.0 Marstons Ave .,, #8 , Hyannisport Jwner: Shirley Stam s Date of Inspection: 4V_` 7 . INSPECTION SUMMARY: Check A, B, C, o/ D: A. :S7ySPASSES: e not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 7 B. S STEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon mpletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass.inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup 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). . broken pipe(s) are 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 r f revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Marstons Ave i , #8, Hyannisport Owner: Shirley Stamps Date of Inspection: C. RTHER 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh." 1 2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN,A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER r � , revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Marstons Ave . , #8, Hyannisport Owner: Shirley Stamps Date of Inspection: D. SY TEM FAILS: You must dicate either "Yes" or "No to each of the following: I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this de ermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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 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. 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. LAR E SYSTEM FAILS: You must dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: Th system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public he Ith and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the apartment for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 160 Marstons Ave . , #8 , Hyannisport Owner: Shirley Stamps Date of Inspection: /,✓"?" rJ n Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been-receiving twrmal 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. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. / The site was inspected for signs of breakout. v _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information.For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] _ The facility owner(and occupants,if different from owner) were provided with information on the proper.maintenanra-0f Subsurface Disposal Systems:_ revised 9/2/98 Page 5ofII + t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iroperty Address: 160 Marstons Ave . , #8, Hyannisport Owner: Shirley Stamps Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: i.f g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flow �i t2( L F*)0, Number of current residents: Garbage grinder(yes or no):/2- a Laundry(separate system) (yes or no)./ G,a If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):V Water meter readings, if available (last two year's usage (gpd): /G i2 Sump Pump(yes or no):&- U Last date of occupancy:-4-A, COMMERCIAL/INDUSTRIAL: Type f establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Greas trap present: (yes or no)_ Indust al Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate o occupancy: 0 R:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORD$ar�d source of ipformation: System pumped as part of inspection: (yes or no)_,&L-) If yes, volume pumped: gallons Reason for pumping: TYPEOF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) C� revised 9/2/98 Page 6ofII ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) *ropertyAddre 160 Marstons Ave . , ##8, Hyannisport Owe: thirley Stamps Date of Inspection: 4/ BUIL NG SEWER: (Locate on site plan) Depth b ow grade:_ Material f construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diame Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) r ` Depth below grader Material of construction: t/concrete metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) li Dimensions: tee. b Sludge depth:_ �� Distance from top of sludge to bottom of outlet tee or-baffle: Scum thickness:— Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: /L) How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees or orbaffles,r epth of liquid level in relation to outlet invert, structural integrity, evidence f leakage, etc.) n GREA TRAP: (locate o site plan) Depth belo grade:_ Material of c nstruction:_concrete_metal Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickne s: Distance from op of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last pu ping: Comments: (recommends on for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of I a age, etc.) 1 revised 9/2/98 P2gc7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 160 Marstons Ave . , #8., Hyannisport Owner: Shirley Stamps Date of Inspection: ^/.+ —9 TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (loc to on site plan) Depth below grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimen ions: Capaci y: gallons Design flow: gallons/day Alarm resent Alarm eve): Alarm in working order: Yes_ No_ Date f previous pumping: Com ants: (con ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi`�ce of solids calry�er, evidence of leakage into or out of box, etc.) - 6 �- , PUMjon MBER:_ (locatite plan) Pumporking order:(Yes or No) Alarmorking order(Yes or No) Com(noteion of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 160 Marstons Ave . , #8 , Hyannisport Owner: Shirley Stamos Date of Inspection: SOIL ABSORPTION SYSTEM.(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type. leaching pits, number: leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number.- Alternative system: Name of Technology: Comments: (note condition of soil, signs of hyulic failure, level of ponding, damp soil, condi 'on o�egetatio9, etc.) r C C POOLS:_ (local on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: )epth of scum layer. Dimensi s of cesspool: Materials of construction: Inclicatior of groundwater: inflow (cesspool must be pumped as part of inspection) 1 Comme s (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI j locate n site plan) l Material of construction: Dimensions: Depth of solids: Commen s: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9 2 98 Page 9 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w PART C SYSTEM INFORMATION(continued) "Irop"Address: 160 Marstons Ave . , #8 ,, H,yannis;port owner: Shirley Stamps Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks i locate all wells within 100' (Locate where public water supply comes into house) / 40— Si J I � may \ 0J revised 9 2 98 Pd door k 11 f Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ropertyAddress: 160 Marstons Ave . , #8 , Hyannisport Owrw: Shirley Stamps Date of Inspection: c pl NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water . Check Cellar Shallow wells Estimated Depth to Groundwater 16' Feet Please indicate all the methods used to determine High Groundwater Elevation: Obt 'ned from Design Plans on record 1-1 Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers a' t Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ci 74 I revised 9/2/98 Page 11ofII COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION , t0�i 44 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� Property Address: 160 Marstons Avenue #8 -o Hyannisport Owner's Name: Jean Hancock (Jane Davis) Owner's Address: 380 Bl i - Hill Rc)ad Chester VT Date of Inspection: 3- s �� G t✓ Name of Inspector:(please print) Wi 11 jam _ . Rob' nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported: below is true,accurate and complete as of the time of the inspection.The inspection was performed based on.my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Suction 15.340 of Title 5(310 CMR 15.000). The system: //Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �� i. �� Date: -ra p The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 approrting authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 MAR `E 0 cis TOWH AB LE ALTH DEPT � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Avenue #8 Hyannisport Owner: Jean Hancock Date of Inspection; 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 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: 1 B. System Conditionally Passes: t One or more system components as described in the"Conditional Pass"section need to be replaced or repaired,The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. 1 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 exfrltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain:! Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl in: 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 : obstruction is tsmsovod 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: 160 Marstons Avenue #8 Hyannisport Owner: Jean Hancock Date of inspection:. ;., -3- 6.-is 9 C_ Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation b the Board of Health in order 9 Y 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: 1 Cesspool or privy is within 50 feet of a surface water i Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 9 4 t 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the systeilii is functioning in a manner that protects the public health,safety and environment: _ The system has aseptic 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 I 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 frodl a 1private water supply well" Method used to determine distance •'This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. i t 3. jOther: a 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• 160 Marstons Avenue #8 yannispor Owner: Jean Hancock Date of Inspection: I;—2 /—6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: , Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'Is 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. _ Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface 1 — 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 private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kato 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(fiat facility and (lie presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.( (Yes/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. arge Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpdl You must indicate either"yes"or"no"to each of the following: (Thee following criteria apply to large systems in addition to the criteria above) yc no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a swface drinking water supply the system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone II of a public water supply well If y?u have answered"yes"to any question in Section E the system is considered a significant threat,or answered "ye "in Section D above the large system bas failed.The(comer cr operator of wry large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 .Marstons Avenue #8 Hyannisport Owner: Jean Hancock Date of inspection: — — , Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection?. _✓_ Were as built plans of the system obtained and examined?(If they were not available note as 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? V 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 j Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] 5 Page 6 of 11 . L OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Marstons Avenue #8 Hyannisport Owner: Jean Hancock Date of Inspection: .i`G -0 g FLOW CONDITIONS RESIDENTIAL Number of bedrooms(actual): Number of bedrooms(design): um ( ) ( gn)� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: X- ! Does residence have a garbage grinder(yes or no)J� Is laundry on a separate sewage system(yes or no):wu[if yes separate inspection required) Laundry system inspected(yes or no)-jam Seasonal use:(yes or no):.,*- Water meter readings,if available(last 2 years usage(gpd)): N/A (ch a rPr3 cy s tem) Sump pump(yes or no):t0 Last date of occupancy:_Z=//_S COMM ERCIAIANDUSTRIAL Type of establishment: Design now(eased 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: OTHF/R(describe): GENERAL INFORMATION Pumping Records Source of information:__ y;L m a M 1Ccec./ C.1- �. Ly Was system pumped as part of the inspection(yes or no):�u If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: r ec L;y I%/'•o i i4- 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): Approximate age of all components,date installed(if known)and source of information: f `'> 07 Were sewage odors detected when arriving at the site(yes or no): i U 6 I Pagc 7 of I I OFFICIAL INSPECTION FORA'I—NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOI(MATION(continued) Property Address: 160 Marstons Avenue #8 Hyannisport Owner: Jean Hancock Date or Inspection: .2---)-4—o BUILDING SENVEn(locate on site plan) Dcpth below grade: Materials of eonstructiow_cast iron _40 PVC_other(explain): Distance fronrivate water supply well or suction lint: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade:�_ Material of eonstruca wncrete—metal fiberglass—poiycdrylene _othcr(explain) — If tank is metal list age.— Is age confnrnned•by a Certificate of Compliance(yes or no :—(attach a copy of certificate) , ; Dimensions:�_--�/ / ut Sludge depth: (j Distance from top of sludge to bottom of outlet Ice or battle: 0�%o Scum thickness: Q Distance from top of scum to top of outlet Ice or baffle: �' r Distance Gom bottom of scum to bottom of outlet tee or bathe: / y, flow were dimensions determined: (y ra - Ta-.")(- Comments(on pumping recommendations, inlet and outlet tee or baflle condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: locate cia site Ian Dcpth below grade:— Material of construction: . concrete metal fiberglass_polyethylene._oilier (explain): / — — Dimensions: / Scum thickness: / Distance from top o scunn to top of outlet ice or bathe: Distance Gom bottom of scum to bottom of outlet lee or baffle: Date of last pumping: Conunents(on pumping recomunendations,inlet and outlet ice of baffle cortditio:n,structural integrity, liquid levels as related to ourYet inverl,evidence of leakage,etc.)- 7 Page 8 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Avenue #8 Hvannisport Owner: J-ean Hancock Date or inspection: TIGHT or HOLDINGYANK: (tank must be pumped at time of inspection)(locate on site plan) / Depth below grade: ' { Material of eonstruc tin:_concrete_metal fiberglass_polyethylene other(explaut): Dimensions: / Capacity: % gallons Design Flow: / gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):— Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTIUBUTION BOX:V(if present must be opencd)(locate on site plan) Depth of liquid level above outlet invert: Conunents(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.): (1 0 4 PUMP CHAMBER:_(locate on site plan) Pumps in working order(}�c"s or no): Alarms in working order(ycs or no): _ Continents(note condition of pump chamber,condition of pumps and appurtenances, etc.): 6 IPage9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Avenue#8. yannispor owner: Jean Hancock Date of Inspection: L-�,ZG-o b✓ SOIL ABSORPTION SYSTEM(SAS):-,---/(locate on site plan,ezcavation'not required) If SAS not located explain why: / T �)P e leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): r CESSPOOLS: 4 (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: Dimensionslof cesspool: Materials of construction: Indication/of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Material sl of construction: DimensiIons: Depth-' solids: Comm4ts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Avenue #8 Hyannisport Owner: Jean Hancoc, Date of Inspection: %- -6 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. ,ESL lay l S. qij 4 Je,,o 1 s G:b Cl� f j� 10 Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Avenue #8 Hyannisport Owner. Jean Hancock Date.of Inspection:- L-a� SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water/ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: —'Observed site(abutting property/observation hole w' in-I S feet of SAS) y/Checked with local Board of Health-explain: ��5I&/LS Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe howyou established the high ground water elevation: /L3 C /7�1�� y 0 11 COMMONIVEALTH OF MASSACHUSETTS !� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PROTECTION '°max ONE RZ\TER STREET, BOSTON D1A,02108 (617) 292-5500 TRUDY CORE Secretan ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address1 60 Marstons Ave .+U8 Ow^Name of hirley Stamps Hyan t , < Address of Owner:l3v 10 ,Centerville Date of Inspection: Name of Inspector:( e not S On S r . am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson Septic Service Mailing Address: P 0 Box 1089, nentervi 1 1 A , MA Telephone Number: nTTB T F, 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ /Fails Inspector's Signature: yU d G� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 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. NOTES AND COMMENTS 9 I® �7 m ��AY TOWN OF BARNSTABLE HEALTH DEPT. revised 9/2/98 Page Iof11 i� Panted on Recycled Paper 1 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "ropercy Address: 160 Marstons Ave . , #8 , Hyannisport ,)wrier: Shirley Stam s Date of Inspection: Ll_,l 7 INSPECTION SUMMARY: Check A, Q C, or D: A. :SYSPASSES:not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S STEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to,be replaced or repaired. The system, upon mpletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup 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). . broken pipe(s) are 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 revised 9/2/98 Page 2of11 f ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Marstons Ave : , #8, Hyannisport Owner: Shirley Stamps ° Date of Inspection: (�,�� c7 7 C. RTHER 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a tone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Marstons Ave. , 8 H annis `Ort F . Y P Owner: Shirley Stamps Date of Inspection: D. SYst TEJMdic FAILS: You muate either-"Yes" or "No to each of the following: aye determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this de ermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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 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. 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. LAR E SYSTEM FAILS: You must dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: Th system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public he Ith and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the apartment for further information. revised 9/2/98 Page 4ofII I 9 `• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. 160 Marstons Ave . , #8, H annis � Property Address: y p Owner: Shirley Stamps Date of Inspection: 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been-receiving wmal 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. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)1 _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenaar."f SubSurface Disposal Systems. revised 9/2/98 Page 5ofII 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Irop"Address: 160 Marstons Ave . , #8, Hyannisport Owner: Shirley Stamps Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: y g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flow 9It0(S,yL i0)0, Number of current residents:Q Garbage grinder(yes or no):/li Laundry(separate system) (yes or no):,,ia If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): ,-1 S4- 1 Water meter readings,if available (last two year's usage (gpd): JL ,Z Sump Pump(yes or no):J4 O Last date of occupancy: (y COMMERCIAL/INDUSTRIAL: Type f establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Greas trap present: (yes or no)_ Indust at Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate o occupancy: O R:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORD a d source of i formation: �� .—W ),17' 9S '9G i99r' 19909- System pumped as part of inspection: (yes or no)_A,,e) If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6ofII I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddre 160 Marstons Ave . , ##8, Hyannisport Owe: thirley Stamps Date of Inspection: BUIL NG SEWER: (Locate on site plan) Depth b ow grade:_ Material f construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diame Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: ✓concrete metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No) i Dimensions:`-r(; `E Sludge depth:_ Distance from top of sludge to bottom of outlet tee or-baffler Scum thickness:__ I Distance from top of scum to top of outlet tee or baffle: F' , Distance from bottom of scum to bottom of outlet tee or baffle: /9 How dimensions were determined: l�i.'v"�6 '► )� 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, Oepth of liquid evel in relation to outlet invert, structural integrity, evidence,of leakage,etc.) -� 4 j .A 4, I , Ji. I GREA TRAP: (locate o site plans Depth belo grade:_ Material of c nstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickne s: Distance from op of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last pu ping: Comments: (recommenda on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of I a age,etc.) 1 revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: 160 Marstons Ave . , #8, Hyannisport Owner: Shirley Stamps Date of Inspection: <j^J�_ g TI T OR HOLDING TANK- (Tank must be pumped prior to, or at time of, inspection) (loc to on site plan) Depth below grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimen ions: Capaci y: gallons Design flow: gallons/day Alarm resent Alarm evel: Alarm in working order: Yes_ No_ Date f previous pumping: Corn ents: (con ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX. (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi Ace of solids ca ry er, evidence of leakage into or out of box, etc.) - 615-- PUMjon MBER:_ (locatte plan) Pumporking order: (Yes or No) Alarmorking order(Yes or No) Com(noteion of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 i N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION O ATION(continued) `roperty Address: 160 Marstons Ave . ; #8 , Hyannis,port. . Owner: Shirley Stamos Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_. leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: .overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hy,�5pulic failure, level of ponding, damp soil, condi 'on of vegetatio , etc.) 1 rz�C.y s �B �� A C A ' .1 C,�✓t r. 6 9.4' C POOLS:_ (locat on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: )epth of scum layer. Dimensi s of cesspool: Materials of construction: Indicatio of groundwater. inflow (cesspool must be pumped as part of inspection) Comme s (note co dition of soil, signs of hydraulic failure, level of,ponding, condition of vegetation, etc.) PRI (locate n site plan) Material of construction: Dimensions: Depth of solids: Commen s: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "'►opertyAddress: 160 Marstons Ave . #8 Hyannis,port: . )weer: Shirley Stamps_ Date of Inspection_ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) / Sj _ j o, revised 9/2/98 Page 10 of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 160 Marstons Ave . , #8 , Hyannisport Owner: Shirley Stamps Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater X Feet Please indicate all the methods used to determine High Groundwater Elevation: Obt 'ned from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) e. !�; s j 4,u,, Te IL revised 9/2/98 Page 11of11 60 Commonwealth of Massachusetts ` Executive Office of Environmental Affairs 9 Department of &' Environmental Protection WiiNam F.Weld Trudy;Coxe ciorNno► ftod" r Argeo Paul Celluccl David B.Struhs Lt Goretnm 6a111,11lwlorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM pDate yYlA�'�S7G!%� � PART A �U CERTIFICATION ddress: / Address of Ownerpection: — 7` ' 7jJ (If different) Name of Inspector. W.E. Robinson SR J l0 Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5—8 7 7 6 J ` W.E. Robinson Septic Service 4,//i7-0,5®/' (f r a l�f P.O. Box 1089 Centerville MA / 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: tP —477 9 4 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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: Check A,B,C,or D: \ \ A] PASSES: I have not found any information which indicates that the system 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 completion of the replacement or repair,passes inspection• Indics yes,no,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 exflltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 Ons Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(61�292-5500 iAJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address .3�e a f''✓1�rS��rr S �� jfn�6 �C�'1 Owner. � )G �/^✓� f �� /? Date of Inspection: Bl SYS CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution bout 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): broken pipe(s)are 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 THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the blic health,safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A 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) ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND S 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 within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply 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 coliform bacteria and volatile organic compounds indicates that the wall is 4ee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) ETHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. A I C h 1'�//i}/'7 Date of Inspection: D) SYSTEM FAIL9:Q ~�� 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 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 1/2 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 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 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. 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. El LARGE STEM FAILS: e following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public 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 r operator of any such system shall bring the system and facility into AM compliance with the groundwater treatment program t.of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Anther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 6 U .��s��S i9/v _111X 1Vly s ; fi Owner. Alc-h iro /\Y� Date of Inspection: Check if the following have been done: ping information was requested of the owner,occupant,and Board of Health. ne of the system components have been pumped for at least 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. 4""facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow G✓The site was inspected for signs of breakout. �11 system components, excluding the Soil Absorption System,have been located on the site. �e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. 4size and location of the Soil Absorption System on the site has been determined based on existing information or rrrr✓✓✓✓approximated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN,F/ORMATION Property Address: ,3� D Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAU Design flow: 4 a gallons Number of bedrooms:,f/A Number of current residents: Garbage grinder(yes or no):� Laundry connected to system(yes or no):�O Seasonal use(yes or no): V t 3 Water meter readings,if bailable: �' G:A-') n L ✓ �- Last date of occupancy: Ald} COMMERCIAL NDUSTRIAL: Type of seta liahment: Design now ons/day Grease trap p nt: (yes or no)_ Industrial W Holding Tank present: (yes or no)_ Non-sanitary discharged to the Title 5 system: (yes or no)_ Water meter ,if available: Last date panty: OTHER: ;000cupancy: Last date GENERAL INFORMATION PUMPING RECORDS and sourcce�of information::/ �y System pumped as part of inspection: (yes or no),A-p If yes,volume pumped: ¢allons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool w cesspool rivy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(esphun) APPROXIMATE AGE of all components,date installed(if known)and source of information: 41 Sewage odors detected when arriving at the site: (yes or no)LL v (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r Property Address: a-!;S��a n/f d' r.Owne /"\y/�/rf Date of Inspection: on: / n SEPTIC TANK LI (locate on site plan) Depth below grade: i Material of construction:Zwncrete_metal_FRP_other(ezplain) G a4, Dimensions: G zt `i' / e Sludge depth: 0 -7S Distance from top of sludge to bottom of outlet tee or baffle:-�—�y Scum thickness: 0 ` I Distance from top of scum to top of outlet tee or baffler j , Distance from bottom of scum to bottom 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 Mats , evidence of leakage,etc.) o (a S o D �'e ►„ ►� 5 /�e G E TRAP:_ (locate n site plan) Depth bel w grade: Material o construction:_concrete_metal_FRP_other(esplain) Dimenri0 Scum f mm top of scum to top of outlet tee or baffle: f}om bottom of scum to bottom of outlet tee or bane:. Comments (repo tion for pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence o leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 2 ,— SYSTEM INFORMATION(continued) ss: 3 Property Addre Owner. Date of Inspection: TIG OR HOLDING TANK:_ (locate site plan) Depth be grade: Material of n:_concrete_metal_FRP—other(explain) Dimensions: Capacity: one DesignT gallons/day Alarm l Comme (conditit tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_G (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) P CHAMBER_ (locate site plan) Pumps' working order:(yes or no) Commen (note on of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .�P 6/ 'ypw/"�/g'w '>1-/1'6sI I S 0� Owner. A Date of Inspeetton: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Tye' leaching Pits,number: Ac 1� leaching chambers,number:_ 1 leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments:(note condition f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) CESS LS:_ (locate on site plan) Number configuration: Depth-top f liquid to inlet invert: Depth of lids layer: Depth of layer: Dimensio of owspool: Mate ' of construction: lndica a of groundwater: inflow(cesspool must be pumped as part of inspection) Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) P (locate • site plan) Materials construction: Dimensions Depth of lids Commen :(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) ri (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I/N�FORMATIO/N(continued) Property Address: D` (�.l I � o Owner. /�/Gh ✓�'/� fR ya9, Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include tier to at least two permanent references landmarks or benchmarks locate all wells within 100' J I� V O I R . \./. _ I� C;�y DEPTH TO GROUNDWATER Depth to groundwater.J..2."' feet method of determination or approximation: 1 5 j L 8)` C 3 (revised 11/03/95) 9 COMMONWEALTH OF MASSACHUSETTS EXECU'I`M OFFICE OF ENVIRONTMENTAL AFFAIRS + DEPARTMENT OF ENVIRONMENTAL PROTECTION z TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORk =� PART A CERTIFICATION �t Property Address: 160 Marston Avenue, #9 ?� Hyanni sport c� L4 Owner's Name: Tim Fuller co Owner's Address: PO Box 776 Hyannisport Date of Inspection: Name of Inspector:(please print) William Robinson, Sr. Company Name• Wm. E. Ro inson, Sr, Septic Service Mailing Address: PO Box 1 089 Centerville Telephone Number: 508-775-8776 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 inson.The inspection was performed based on my training and experience in the proper fimction and maintenancq of on site sewage disposal systems_I am a DEP approved system inspector pursuant to Section 15—UO of Title 5(310 CMR 15.M). The system: -t `asses Conditionally Passes Needs Further£valuati y the Local Approving Authority Fai Inspector's Signature: Date: A;t The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shaved system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hoar the system will perform in the future under the same or different conditions of use. C Title 5 Inspection.Form 6115/-OUO page I s _ Page 2 of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTOM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marston Avenue, 09 yannispor Owner: Tim Fuller Date of Inspection: Inspection y ummary: Check AAC,D or E/ALWAYS complete all of-Section D A. Syst 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: ej B. System Conditionally Passes: One or more system components as descnlsed in the"Conditional Pass"section need to be replaced or_ repair .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structu ally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent.Systeawill bass inspection:if`the-__- existing U nk is replaced with a complying septic tank2smpprovedby the Board of health. *A metal tic tank will pass inspection if it is sow sozzad,not leg and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND expl in: bservation of sewage backup or out or high static hid is the distribution box due to broken or obs ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): brokenpipe(s)are replaced f\ obsUuctftmjszcmvvcd distributiom box is leveled or replaced ND exp in: Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspec ion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: JL_ L ` Pase 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marston Avenue, #9 yannispor Owner: Tim u er Date of Inspection: C. urther 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 failin to protect public health,safety or the environment. 1. S tem will pass unless Board of Health determines in accordance with 310 CMR 15303(l)(b)that the sy tem is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Syst m will fail unless the Board of Health(and Public Water Supplier,H any)determines that the system i 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 sur ace water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS`is.within a Zone I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: i 3 c Page 4 of 11 ` OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSE SYSTEM .INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: 160 Marston Avenue, #9 Hyannis port Owner: Tim Fuller Date of Inspection: !R-6- -o-7 D. ystem Failure Criteria applicable to all systems: You ust indicate"yes"or"no"to each of the following for all inspections; Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or " esspool iquid depth in cesspool is less than 6'below invert or available volume is less than'/z day flow equired pumping more than 4 times in the last year NOT due m clogged or obstructed pipe(s).Number f times pumped y portion of the SAS,cesspool or privy is glow high ground water elevation. y portion of cesspool or privy is within 100 few tafa surface:water supply or tributary to a surface ater supply. y portion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water s pply well with no acceptable water quality analysis.Inis system passes if the well water analysis,. rformed at a DEP certified laboratory,for conforms bacteria and volatile organic compounds i dicates that the well is free from pollution from that facility and the presence of ammonia itrogen and nitrate nitrogen is equal to or less than 5 ppmt larovided �+�atlaer.failare•eriteri� . .. re triggered.A copy of the analysis be to this farm.] (Y o)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 15.303;therefore late system fails.The system owner should contact the Board of. Health to determine what will be necessary to-correct the bihne- E. La a Systems: To be c nsidered a large system thesystaminuAservea lbw with a design flow of 10,000 gpd to 15,000 gpd• You mu indicate either"yes"or"no"to each of the following: (The foil ing criteria apply to large systems in addition to the criteria above) yes no — _ e system is within 400 feet of a surface drinking water supply — — e system is within 200 feet of a tributary to a surface drinking water supply _ — it e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Z ne 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Se ion D above the large system has failed.The owner or operator of any large system considered a significant eat under Section E or failed tinder Section D shall upgrade the system in accordance with 310 CMR 15.304.Th system owner should contact the appropriate regional office of the Department. 4 L., a Page 5 of I z OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - CIIECKLIST Propertv Address: 160 Marston Avenue, #9 Hyannisport Owner: Tim Fuller Date of Inspection: ,?6-22:�7 Check if the following have been done.You most indicate"yes"or`ho"as to each of the following: Yes No 1 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? t1 Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? . _ Was the site inspected for suns of break out? r/ 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 ofligoid,depth of sludge and depth of scum? _ v/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 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)] G ; Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _3, PART C SYSTEM INFORMATION Property Address: 160 Marston Avenue, #9 Hyannisport Owner: Tim Fuller Date of Inspection: 2-IA-or"' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- L Number of bedrooms(actual): DESIGN flow based on 310 CMR�5203(for example: 110 gpd x#of bedrooms): D Number of current residents: Does residence have a garbage grinder(yes or no):kc Is laundry on a separate sewage system(yes or no):X-,O[if yes separate inspection required] Laundry system inspected(yes or no) Seasonal use:(yes or no):.It--�3 Water meter readings,if a ai le(last 2 years usage(gpd)). a g Sump pump(yes or no):A- Last date of occupancy: t/ i' COMME CIAL/INDUSTRIAL Type of a lishment: Design flo (based on 310 CMR 15.203): wd Basis of de ign flow(seats/personsisgftetc) Grease trap present(yes or no): Industrial ante holding tank present(yes or no): Non-sari waste discharged to the Tide 5 system(yes or no): Water me r readings,if available: Last date f occupancy/use: OTHE (describe): GAL IlIFORMATION Pumping Records Source of information: .bd-.1� Was system pumped as part of the inspection(yes or no):�.v If yes,volume pumped: ons-Howw_as_quarim y pumped tletetmined? Reason for pumping: TY ,ZOF SYSTEM G eptic 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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):_,& 0 6 Paee 7 of l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marston Avenue, 09 Hyannisporf: Owner: Tim Fuller. Date of inspection: �a1 BUILDING tWER(locate on site glen) Depth Belo grade: Materials o construction:_cast iron 40 PVC_other(explain): Distance fr m private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc-): SEPTIC TANK: - (locate on site plan) a Depth below grade: _ Material of construction: _ &SS__.Fob Ylene other(explain) If tank is metal list age:— is age onfltn ed by a C�of ComPHa nor or no): _--(attach a spy of c certificate) a Dimensions: Sludge depth::Q Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: • ' Distance from top of scum to top of outlet tee or baffle: e Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: 0 of outlet 2�--,/ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence o l etc-): , P - •� v GREASE T AP: (locate on site plan) u Depth below grade:— Material of nstruction: concrete metal fiberglass ©lYethYlene other (explain): Dimension Scum chic ess: Distance om top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of 1 t pumping: Comore (on pumping recommendations,inlet and wtlet tee or baffle condition,structural integrity,liquid levels as relate to outlet invert,evidence of leakage;etc_): 7 gage 8 of I I OFFICIAL INSPECTION FORM—NOT FOR LTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL _ SPECTION FORM PANT C SYSTEM INFOR!I ATIO ed) Property Address: 160 Marston Avenuer #9 Hvanni sport Owner: Tim Fu 1 1 ar Date of inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below de: Material of co structon- consxete metal fiberglass_ _polyethylene atlter(explain}: 1 - Dimensions Capacity: / a+allons Design Fldw: gaIIonJdhy Alarm pr�sent(yes or no): Alarm level: Alarm in working dztler(yes or no): Date ofA�st pumping: Commi is (condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be apened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to tmtlets egLst my evidence ofsolids carryover,any evidence of leakage into or out of box,etc.): f PUMP CHAMBER- (locate on site playa) Pumps in worki - order(yes or no): Alarms in wor ' g order(yes or no): Comments (n a condition of pump chamber,condition of pumps 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: 160 Marston Avenue, 09 yannisport Owner: Tim Fu er Date of Inspection: -d &f y / SOIL ABSORPTION SYSTEM(SAS): �: (locate on site plan,excavation not required) If SAS not located explain why: •Ty✓pe leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system "Type/name of technoIogy: Comments(note condition of soil,signs of hydraulic failure,level of pondiug,damp soil,condition of vegetation, etc.): p '° CESSPOO (cesspool must be pumped'as part of inspection)(locate on site plan) Number an configuration: Depth-to of liquid to inlet invert: - Depth of s ids layer: Depth of s layer: Dimensio of cesspool: Materials f construction: Indication of groundwater inflow(yes or no): Commen (note condition of soil,signs ofhydraufic faih*-e,level of ponding,condition of vegetation,etc_): PRIVY: (locate on site plan) Material of construction: — Dimensi ns: Depth o solids: Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc_): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT-FO VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address. 160 Marston Avenue, #9 yannispor owner: Tim Fu er Date of Inspection: 0 ;? o - 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. l 1 i f 117 p oi ti 10 l -T Page 1 I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marston Avenue, #9 Hyannisport Owner• Tim Fuller Date of Inspection: 7-1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_I feet Please indicate(check)all methods used to determine the high ground water elevation: obtained from system design plans on record-If checked,date of design plan reviewed: /Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board.of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explam: I' You must describe how you established the high ground water elevation: ,/ ll Town of Barnstable Op IME tpk ti�P� ti* Regulatory Services snxxsrnscK Thomas F. Geiler,Director 16 MASS.. Public Health Division AtFD��p Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 5087790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. I REMOVED 7 R , c � � MAY 2 6 1995 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI POW DEPT Address of property , MWN OF RSPN Owner's name Harbor Village Unit ,�k 160 Marston Date of Inspection Trudy Soucy NWMNWU 5-13-95 U30N1im PART A CHECKLIST �661 9 z �dW check if the following have been done: vl Pumping information was requested of the owner, occt:pant, ar.dWR rd of /Health. V None of the system components have been pumped for at least 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. y The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. Y All system components, excluding the SAS, have been located on the • /site. t/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. I/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS.- t t 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _ number of bedrooms _ number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of informslfion: _ 'LU. 8 0 J'b L 6 7L . l/C Az System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy yC= Shared system (yes or no) (if yes, attach previous insection records, if any) p Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no . 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: / , / material of construction: t� concrete metal FRP other(explain) - r dimensions: G 4 1 1 �► �. sludge depth distance from top of sludge to bottom of outlet tee or baffle =' scum thickness distance from top of scum to top of outlet tee or baffle _' distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) 4'a DISTRIBUTION BOX: (locate on site plan) n depth of liquid level above outlet invert Comments: ,(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER (locate on site plan) �l/ _ pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, . recommendations for maintenance or repairs,etc. ) 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM .IN/FORMATION continued SOIL ABSORPTION SYSTEM (SAS) : V (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 and number _ leaching chambers and number ? A b leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration p 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 soil, signs of hydraulic failure, level of ponding, condition of veg tation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, .signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance' or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE E_SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 12 ' SUBSURFACE SEWAGE DISPOSAL SYSTEMS INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined'f, explain why not) Backup of sewage into facility? . Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6". below invert or available volume< 1 2 flow? / day IV Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? AV within 50 feet of a surface water? within 100 feet of a surface water supply or tributary ry to a surface water supply? within a Zone I of a public well? . within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? 4-11 within 50 feet of a private water supply .well? less than 100 feet but greater than 50 feet from te wat supply well with no acceptable water quality analysis?vaIf thee well has been analyzed to be acceptable, attach co PY of well . for coliform bacteria, volatile organic compounds, ammoniater nitrogensll and nitrate nitrogen. 1 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION ame of Inspector W.E. Robinson Jr 'ompany Name W.E. Robinson Septic Service :ompany Address P.O. Box 1089 Centerville MA 02632 'ertification Statement certify that I have personally inspected the sewage disposal system at his address and that the information reported is true, accurate and omplete as of the time of inspection. The inspection was performed and ny recommendations regarding upgrade, maintenance and repair are onsistent with my training and experience in the proper function and anitenance of on-site sewage disposal systems. hec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. . nspector's Signature ate riginal to system owner opies to: Buyer (if applicable) Approving authority COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS /S� `J DEPARTMENT OF ENVIRONMENTAL PROTECTION /0 1� C4 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I CERTIFICATION I Property Address: 160 Marstons Ave #1 4 ' Hyannisport Owner's Name: Martha .Durgin Owner's Address: 115 Cape Pointe Circle Jupiter, FL. 33477 Date of Inspection: b, �^ d" Name'of Inspector:(please print) Wi 1 1 i am E_ •Rob nson Sr. Company Name: William E. Robinson Septic Service rn. Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 ~§ 4.A 3y ca CERTIFICATION STATEMENT Ln r— cn rn i certify that 1 have personally inspected the sewage disposal system at this address and that the inform tion 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 Sec' n 15340 of Title 5(310 CMR 15.000). The system: asses - Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails /� Inspector's Signature: �~ ✓"" Dote:��-9 '4 'r The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatttror 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 approxing authority. Notes and Comments 4 ****This report only describes conditions at the time of inspection and under the conditions of use at that titre.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Ave #14 Fly_annisport Owner: Martha ?Durgin Date of Inspection: C - y"C Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. :tn- ot asses• 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: B. S stem Conditionally Passes: ne or more system components as described in the'.'Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y s,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,aibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the - existing"is replaced with a complying septic tank as approved by the Board of Health. •A metal si�ptic 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 oid is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box aue to•broken or _ obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND plain: The system required pumping more than 4 canes a`year due to broken or obrntiKted pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rzmovcd 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: 160 Marstons Ave #14 _ _jL)Lannisport Owner: Martha_;Durg 'n Dale of Inspection: ._ -. �Q C. Further Evaluation is Required by the Board of Health: Ail ditions exist which require further evaluation by the Board of Health in order to determine if the system protect public health,safety or the environment. tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the em is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh 2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the Sys(e 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 s rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 fronl a private water supply well** Method used to determine distance "This system passes if the well water analysis,performed ara 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. f Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Ave #14 _Hvannisport Owner: Martha �' Durgin Date of Inspection:�- —G D. S) tern Failure Criteria applicable to all systems: You rn t indicate'). res".or"no"to each of the following for all inspections: Yes N _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or cesspool tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool iquid depth in cesspool is less than 6"below invert or available volume is less than%day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. ey portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface ter supply. y portion of a cesspool or,privy is within a Zone 1 of a public well. — Aty portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 f^_et from a private water s ipply well with no acceptable water quality analysis.(This system passes if the well water analysis, errormed at a DEP certified laboratory,for conform bacteria and volatile organic compounds i dicates that the well is free.from pollution from that facility and the presence of ammonia itrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria re triggered.A copy of the analysis must be attached to this forma (Y /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. L rge Systems:To b considered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000 gp Y must indicate either"yes"or"no"to each of the following: (Tlt following criteria apply to large systems in addition to die criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you h$ve answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"mISection D above the large system has famed.The vwrta or operator of wry large system considered a signific nt threat under.Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, Fhc system owner should contact the appropriate regional office of the Department. 4 Page S of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 Marstons Ave #14 Hvannisport Owner: Martha Durgin Date of Inspection: L txr LF 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 J Were any of the system components pumped out in the previous two weeks? cap _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection?:. ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _L — Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? c/ 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? �as 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 Xisting information.For example,a plan at the Board of Health. c/— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable)[310 CMR I5.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Marstons Ave #1 4 ; HvannisportI1-rt owner: Martha Durgin Date of Inspection: 17 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):9 6 d Number of current residents: A-1 1, Does residence have a garbage der(yes or no): Is laundry on a separate sewage system(yes or no)-.A o [if yes separate inspection required] Laundry system inspected(yes or no): o Seasonal use:(yes or no): s Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): A.,D — Last date of occupancy:�A,,/.A' COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow/�asn 3 CMR 15.203): gpd Basis of desiats/persons/sgfl,etc.): Grease trap s or no): Industrial wg tank present(yes or no):Non-sanitarycharged to the Title 5 system(yes or no):Water meter if available: Last date of /use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: .i. IC. Cl Was system pumped as part of the inspection(yes or no): O If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Ov ow cesspool un _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tigbt tank '_Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 ` 1'agc 7 of I I OFFICIAL INSPECTION FOR114—NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIATION(continued) Properly Address: 160 Marstons Ave #14 Hyannisport Owner: Martha Durgiin Date or Inspectlon: BUILDING SEW (locate on site plait) Dcptlt below gra c: Materials of c� struction:_cast iron _40 PVC_ol}ter(explain): Distance fron private water supply well or suction lute: Comments n condition of juutts,venling,cvidcncc of leakage,etc.): SEPTIC TANK:/(locate on site plan) Depth below grade: , Material of construction: ✓o,ctc1e metal fiberglass youlyethylene _ot)tci(explain) — _ If tank is metal list age:— Is age confinned•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ; Dimensions: Sludge depth. 7 Distance from top of sludge to bottom of oullct Ice or baffle: ? e Scuni thickness: Distance front top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle:4/flow were dimensions determined: - Comments(on pumping reconunendations, inlet and outlet ice or baffle condition,structwal integrity,liquid levels as related to oullc(invert,evidence/>of Ieaka e,etc.): , GREASE TRAP:_(locate gn to plan) - Dcpdi below grade:_ Material of construction: concrete nietal fiberglass_polyelliylene__outer (explain): — Dimensions: Scum thickness: Distance from to of scum to top of outlet Ice or baffle: Distance from otloni of scum to bottonn of outlet tee or baffle: Date of last piping: Conunent (on pumping reconunendations, inlet and outlet ice or banle condition,structural integrity, liquid levels as relat to outlet invert,cvidcncc of leakage,etc.): 7 'age 8 of 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C R SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #14 Hyannisnor_tY_ OwntrMarthaDurgin Dalt or Imsptcllon: TIGIIT or 110LDING ANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construct• n:___concrete_metal_fiberglass_polyethylene o►her(explabi): Dimensions: Capacity: gallons k Design Flow: gallons/day Alann present Yes or no): Alarm level: Alarm in working order(yes or no):— Date of last p mping.. Cotunents( ondition of alarm and float switches,etc.): DISTIUBUTION BOX:—(if present must be opcned)(locate on site plan) Depth of liquid level above outlet invert: 6 Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of - leakage into or out of box,ctc.): PUMP CHAMBER: � cate on site plan) Pumps in working order ycs or no): Alarms in working or r(yes or no):— Conunents(note con ition of pump chamber,condition of pumps and appurtenaiices,etc.): Page 9 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #1 4 Hyn-n liSDort Owner: Martha Durgin Date of Inspection: I ':PIT! SOIL ABSORPTION SYSTEM(SAS): `� (locate on site plan,excavation not required) If SAS not located explain why: I'leaching P�its,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ZA- CESSPOOLS: �( sspool must be pumped as part of inspection)(locate on site plan) Number and config ation: _ Depth—top of 1iq d to inlet invert: Depth of solids I yer: Depth of scum yer. Dimensions o cesspool: Materials of onstruction: Indication groundwater inflow(yes or no): Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (I ate on site plan) Materials of nstruction: Dimension . Depth of lids: Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #14 t ;►r(l Hyannisport Owner: Martha Durgin Date of Inspection: = ,5'� 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. 10 Page•i l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave #14 Hyann i_s_port Owner. Martha ,Durgin Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describ how,�, oyy established the high ground water elevation: liJc�Lir :z 6 c 2 I 11 •.x 7 ,per .. \ COMMONWEALTH OF MASSACHUSETTS '. �EXECUTIVE;OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF:ENVIRONMENTAL PKOTIVErWI ® G� mlp Q Z TW V MI DEC 1 0 2002 r TOWN OF'BAR.NSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 2 CERTIFICATION MAP ll00` PARCEL- �w� (S Property Address- 1 Ra VJl Jags... .'/ LOT �a n n i ��i>�� - _ Owner's Name: Owner's Address: 191 Z- Date of Inspection: � Name of Inspector:(please print) W11 1 i am F_ .Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O"Box' 1,089 Centerville;,. MA ; Telephone Number: ( 5081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported_ below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant toSection 15.340 of Title 5(310 CMR 15.000). The system: t,Passes Conditionally Passes - Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature; _I Date: -d�_o 2_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaWi�or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different" conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 F OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAMDISPOSAL SYSTEM INSPECTION FORM PART A ued CERTIFICATION (continued): aar ess: 14 Harl, A Property HyannisAort Owner. Bill Garvey Date of inspec tion: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: - l have not fotu'id 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: B. ystem Conditionally Passes: One or more system to as described in the"Conditional Pass"section need to'be replaced or repaire .The system,upon completion of the replacement or repair,as approved by.the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, xhibiu substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing is replaced with a complying septic tank as approved by the kingBoar nd Health: •A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND expla' Ob ervation of sewage backup or break out or high static water level in the distribution box due to broken or obstructedpipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval o Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl e system required pumping more than 4 tenses a y�due to broken or obstructed pipe(s)•The system will pass in ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND expl in: Page 3 of l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM .::PART A . CERTIFICATION(continued) Property Address: 14 Harbor Village Hyannisport Owner: Bill Garvey Date of Inspection: `l_®mot C. Further Evaluation is Required by the Board of Health: t.., )1aig ditions exist which require further evaluation by the Board of Health in order to determine if the system protect public health,safety or the environment. tem will pass unless Board of Health determines id'accordance with 310 CMR 15.303(l)(b)that theem.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 30.feet of a'bordering vegetated wetland or a salt marsh 2. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is,fu"fjoning in a manner that protects,the public health,safety and environment-: The system has aseptic tank and soil absorption system(SAS)and the SAS.is withinF1-0.0 feet of a su face 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 ivate water supply well••.Method used to determine distance 'This system passes if the well water analysis,performed at a DEP certified laboratory,for colifotm - acteria and volatile organic compounds indicates that the well is free from pollution from that facility and: the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 S r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'PART A CERTIFICATION;(continued) Property Address: 1 4 Harbor' Village2.2 yannisport i Garvey Owner: — 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 e u O ground or overloaded or urfa a r cesspool Discharge effluent wat r�ge due to and SA ooverloaded or 'or ponding of euent to the surface of . gr :. , 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 thin 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. _ 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. _ Anypbrtion 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'privati 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 monia indicates that the well is tree from pollution from that facility and the that no other of a failure criteria nitrogen and nitrate nitrogen is equal to or less than 5 m,provided are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design Clow of 10,000 gpd to 15,000 gP Yo must indicate either"yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary.to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public watersupply well or answe red If yo have answered"yes"to any question in S system is E the syst is c unsidered a significant threat, "yes'in Section D above the large system has fmkd.The owner or operator Of any large system considered a sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15 04.The system owner should contact the appropriate regional office of the Department. 4 r i Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM CHECKLIST Property Address: 14 Harbor Village HUann i G=ort Owner: 'Rill—Garvey Date of Inspection: 1,2--u —o',L. 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 _ v/Were any of the system components pumped out in the previous two weeks? _ / f / Has the system received normal flows in the previous two week period? ., / 4 x V Have large volumes of water been introduced to the system recently or as part of this inspection? _.z — Were as built plans of the system obtained and examined?(If they were not-available note as_N/A) ✓ _ Was the facility or dwelling inspected for signs of:sewage back up? Was'the site inspected for signs of break Out? , ✓ Were all system components,excluding the SAS,located on site ._JL — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected`for the,condition of the bafflees 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 approximationof distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL.INSPECTION FORM ,NOT FOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEM INFORMATION Property Address: 14 Harbor Village Hyannispor Owner: i Garvey Date of Inspection: / -61-e>`�- FLOW CONDITIONS RESIDENTIAL - Number of bedrooms(design):. Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). 1.7 U Number of current residents: 0 Does residence have a garbage grinder(yes or no):N = _: Is laundry on a separate sewage system(yes or no):,A- [if yes separate inspection required] Laundry system inspected(yes or no)`.7� Seasonal use:(yes or no):�L-f ( Y g (gpd)).-'-,'n a sha Water meter readings,if available(last ears usage d �` '' 'water meter - - Sump pump(yes or no):r Last date of occupancy:_,- d CO ME IALIINDUSTRIAL'' Type of es ta lishment: Design flo (based on 310 CMR 15.203): gpd Basis of d sign now(seats/persons/sqft,etc.): Grease tr present(yes or no): Industrial waste holding tank present(yes or no):_ Non-san' waste discharged to the Title 5 system(yes or no): Water ter readings,if available: Last da of occupancy/use: OTH (describe): GENERAL INFORMATION Pumping Records Source of information: SZ,5 C Vax Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Ov 'rflow cesspool _ vY _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): Approximate age of all components,date installed(if kn wn and source of information: ,Z 7© R � o Were sewage odors detected when arriving at the site(yes or no): i(1 6 Page 7 of I I OFFICIAL INSPECTI.ON FORM NOT'FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C : . SYSTEM INFORMATION(continued) Property Address: 14 Harbor Village yannispor Owner• ii i Garvey— Date of Inspection: j PL-o rt-- c}-- BUI ING SEWER(locate on site plan) Depth elow grade: Mated Is of construction _castiron 40 PVC other.(explain): Di;tan a from private water.supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: /(locate on site plan) Depth below grade:Za— 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) i G� Dimensions: Z at G i-:z_ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: c Scum thickness: ` Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: '4-)„ How were dimensions determined: dr 9"Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels" as related to outlet invert,evidence of.leakage,etc.): (!'V A j '/ .e 1-✓f` �e �t' V� C�vti2SC`RA"►d% ,/ S'�l GRE E TRAP:_(locate on site plan) Depth b ow grade: Material f construction:_concrete_metal_fiberglass_polyethylene_other. (explain): Dimensio s: Scum chic ess: Distance m top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of I t pumping: Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related o outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION„FORM'. PART C SYSTEMANFORMATION(continued) Address. 14 Ha r hnr Szi 11age _. Property _._ Bill Gar-vey Owner: ; Date of Inspection: must be pumped at time of inspection)(locate on site plan) TIGH or HOLDING TANK: (tank Depth be ow grade: fiber lass olyethylene other(ezplain), Material f construction: concrete metal g _p Dimensi s: Capacity' gallons ` Design F ow: gallons/day Alarm p esent(yes or no): Alarm I vel: _ Alarm in working order(yes or no): Date of last Pumping'— Co nts(condition of alarm and float switches,etc.): DISTRIBU TION BOX: `�/of present must be opened)(locate on site plan) Depth of liquid level above outlet invert: evidence of solids carryover,any evidence of , Com ments(note if box is level and distribution to outlets equal,any leakage into or out of box,etc.): PUMP CHA DER: (locate on site plan) work order(yes or no): Pumps m g Alarms in work ng order(yes or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'' PART.0__ x SYSTEM INFORMATION(continued) Property Address: 14 Harbor Village Hyannisport Owner: Bill Garvey - - Date of Inspection:,l 2- -•G 9'—o 2 SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,ezcavation..not required) - 1 If SAS not located explain wh y Type ��eaching pits,number: A-, 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.): _} JJ // ��(//J JJ /,// �b vt^�,'� �JE Z:�/(_ ii� b+�/ � Cif � Cam. / d.L C SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Num er and configuration: Depth top of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimens ons of cesspool: Materia of construction: Indicati of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materia s of construction: Dimen ons: Depth f solids: Co nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): f 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO&A SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Harbor Village Hyannisport F . Owner: Bill Garvey Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landinark's or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building: 7� O C J� Z I- �v Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Harbor Vi 11a.ge Hyannis c)rt_ Owner:_ Fti 1 1 Garvey Date.of Inspection: lam—67-02. SITE EXAM Slope Surface water Check cellar Shallow wells oz Estimated depth to ground water 2 6 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how yo established the high�iround water a vatio r� c 10A Lo I1 16011nit 1°4 Marston Av' 'e- :HarborVillage� P '�' ,�� n�Y� r v NEB. 42101/3 RED 10% ® 0 a 0 A �,= Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. City/Town State Zip Code Date of Inspection 'Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection It�l Company Name 74 Beldan Ln. ICI Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected.the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/2/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. W. ge t5ins•3/13 Title 5 Official Inspection For Disposal System•Page 1 of 17 r THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M AG(� LE DATA ® 0 ` 'CO �j l?f 0�� of a�,nstabli� Barnstable Poste // � ark Certified FHere A kmmica0v aeceF a ,- r' 7 Services Department Retum r idorsement �CJ• y Division , iestrictedt)elive ui e� lic Health Division m indorsement Fteq / 1 'in Street, Hyannis MA 02601 2007 Total Postage&Fees TxRYN BAR G ARRICK & E-1JN1T 15 160 ivIARSTON AV 02647 Thomas F.Geiler,Director 160 M, S PORT MA _ Thomas A.McKean,Cxo CERTIFIED MAILj#7012-1010-0000-2848 -0745 March 28, 2013 GARRICK& KATHRYN BAUER 160 MARSTON AVE-UNIT 15 IMPORTANT NOTICE 0 c, HYANNIS PORT,MA 02647 Map & Parcel: 288- 180r The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old,septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE BO RD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW Enc. :A.SEwER connectEetters Stewart Creek Sewer ConnectsWAILING L.etA Sewer 2P s Mer ed 3-28-13 Yr2015.doc Q S � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 Marston Avenue#15 M Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 160 Marston Ave Hyannis is served by a shared Title V septic system consisting of 2000 gallon septic tank, distribution box and 4 precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this property has been ordered to connect to town sewer on or before 3/30/2015. (see attached) B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no",or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health Y 9 P safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is Hyannis Ma 02601 9/2/2013 required for every y page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper m6intenance 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): 10 Number of bedrooms (actual): 10 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1100 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ .No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: M Septic tank, distribution box, soil absorption system ❑ Single cesspool I ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2feet 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 3 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: 2000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown 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 Y Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10.1 How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Pi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is Hyannis Ma 02601 9/2/2013 required for every y page. Cityfrown 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 4 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of past failure 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 I Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 L_ Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is Hyannis Ma 02601 9/2/2013 required for every y page. Cityfrown 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 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 rage av va AA OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave. Unit #15 yannisport Owner. Bishop Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a-sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 1 � c� IY b v L -30 T 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 160 Marston Avenue#15 Property Address Garrick& Kathryn Bauer Owner Owner's Name information is required for every Hyannis Ma 02601 9/2/2013 page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • ` COMMONWEALTH OF MASSACHUSETTS 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 Property Address: 1 ,5 Owner's Name: 1 _tn• (-� i ,i(1 ; Owner's Address: ,T Date of Inspection:_ —��,.-6 Name of Inspector:(please print) Company Name:William E. Robinson Septic Service Mailing Address: P O Box 1089 _Centerville, MA r_ Telephone Number: ( 5081 77S-977f; ` CERTIFICATION STATEMENT , 1 certify that I have personally inspected the sewage disposal system at this address and that the information'repogca below is true,accurate and complete'as of the time of the inspettion_The inspection was performed based on my_h <Y;training and experience in the proper function and maintenance of on site sewage disposal systems_ am a DE>s a approved system inspector pursuant to Se ion 15340 of Title 5(310 ChtR 15.000)_ The systetrt ` asses Conditionally Passes } Needs Further Evaluation by the Local Approving Authori ' Fails > Inspector's Signature: / Date: �U " The system inspector`shall submit a copy of this inspection report to the Approving Authority(Board of Heatth or --i 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 approxing authority. K, Notes and Comments "'•Thu report only describes conditions at the time otinspection and under,the conditions otuse at that time_This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6I152000 page I ,s t'y 4 1 Page 2 of.l t - OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Cj�ERTIFICATION(continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section D A. /1have Passes: ` not found any infoanyrmation - 15.303 or in 310 CMR 15.304 exu atAny failure criteria of evaluated areindicatedilure ebelo,v ria described in 3 iU CMR Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y.N,ND)in the for the following statements.If"not determined"please. , explain. Th septic tank is metal and over 20 years old"or the septic`tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or extiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal icptic tank will pass inspection if it is structurally sound.not leaking and if a,Cettificate of Compliance indicatin that the tank is less than 20 years old is available: ND expla : nervation of sewage backup or break out or high static water level in the distribution box due twbroken or obstruct pipes)or due to a broken,settled,or uneven distribution box.System will pass inspection if(with approval f Board of Heallh): , broken pipe(s)are replaced obstruction is removed ' distribution box is leveled or laced nF ND expla' Th system required pumping more than 4 Brien a y�due to broken or obsovacd pipe(s).The system will pass inspec ion if(with approval of the Board of Health): broken pipe(s)are replaced' t'.. obsb ictinn is icmovcd v ND explain: t Page 3 of I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ilest kvv AJ-_ - e 3 a Owner: Date of Inspection: 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 fail' to protect public health,safety or the environment, 1, yssem will pass unless Board of Health determines in accordance with 310 CMR I5:303(1)(b)that the stem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone i 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 front a private water supply well— Method used to determine distance ' 'This system passes if the welt water analysis,performed at a DEP certified laboratory,for coliform acteria and volatile organic compounds indicates that the well is free 5tom pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other' ailure criteria are triggered.A copy of the analysis must be attached to this form. ' 3. " (her: f r 3 S Page 4 of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .jyt CL;fJ'lIt S Yi'u Owner: V t'1( L( Date of Inspection: `d D. stem Failure Criteria applicable to all systems: You m st indicate' es"or"no"to each of the following for all inspections: . Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool _ tatic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or c sspool Lt uid depth in cesspool is less than 6"below invert or available volume is less than day flow R uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o times pumped portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100_feet of a surface water supply or tributary to a surface w ter supply. . . y portion of a cesspool or privy is within a Zone I of a public well. y 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 Kafir supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) ( es/No)The system fails.I have determined that one or more o(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. Larg Systems: . To be con idered a large system the system must serve a facility with a.design flow of 10,000 gpd to.15,000 gpd- You must dicate either"yes"or"no"to each of the following: (Tlie fol wing criteria apply to large systems in addition to the criteria above) yes no the ystem is within 400 feet of a surface drinking water supply the s stem is within 200 feet of a tributary to a surface drinking water supply the sy item is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I of a public water supply well I f you have answ ed"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section above the large system has famed.The owner or operator of tiny large system considered a significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. 4 Page 5 or i i " r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B' : CHECKLIST = Property Address: CA6"A Avti'ti Owner: Date of Insp— ection:_ Q�l L�' S T y Check if the following have been done.You must indicate"yes"or"no"as to each of the following: ` Yes Nof Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? . ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) y Was the facility or dwelling inspected for signs of sewage,backup? , _ _ Was the site inspected for signs of breakout? �/ • 1. •• .,., Were all system components,excluding the SAS,located on site? _ _ Were the septic tank:manholes uncovered,opened,and the interior of the tank inspected foe 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 or 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. _V/_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance ' is unacceptable)[310 CMR 15.302(3)(b)] ' 5 f Y Page 6 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. 1` SYSTEM INFORMATION Property Address: L"o`AGE:;s4u , A r(-m-t. Owner: �►t��'� c i �� Date of Inspection: �/Jf•'i� FLOW CONDITIONS R.ESWENTIAI. Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: i 10 gpd x#!of bedrooms): Z Number of current residents:_ Does residence have a garbage grinder(yes of na):,�LJ Is laundry on a separate sewage system(yes or no):X✓U[if yes separate inspection required] s L .t+t 6`•` Laundry system inspected(yes or no): I� Seasonal use:(yes or no):)Lv'-5 Water meter readings,if available(last 2 years usage(gpd)): c d y Er J�— Sump pump(yes or no): ti 1) Last date of occupancy:.'T_j COMMERCIAIJINDUSTRIAL ` Type of establishment: Design flow(based on 310 CUR 15.203): gpd Basis of design flow(seatslpersons/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 occupancyluse: OTHER(describe): , GENERAL INFORMATION Pumping Records Source of information: y`.w•z L y, Was system pumped as part of the inspection(yes or no):is If yes,volume pumped:''_' < ' gallons—How was quantity pumped determined? Reason for pumping: TYP, OF SYSTEM ` ✓Septic tank,distribution box,soil absorption system Single cesspool , __..Overflow cesspool nyy . Y hared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativdAltemative 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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): .4 41 6 fall 7 .,f I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUN,rAKY ASSESSIIIENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION_FORM PART C SYSTEM 1NFORALATION(continued) Property Addrtss: 1(fCJ/�,'Vc j Z I�t ►�ti> 1S Date of Irtspeellon: "V BUiLUING SEN► R(Luca un silt plan) Dcpol below grade: Materials of construe it:_cast irun _40 1'VC outer(explain). Distance from priv watcr supply►ell or Sur lion line:_ Cununerrts(oil condition of juints,vatting,evidence u(Icakage,ctc.)_ F SL"PTIC TANK:`(locate on site Platt) Dcpth below grade: !V 3 Material of construction:_conucte ntctal fiberglass pulyedlylcrte "tank is melal list age:_ Is age cunftnned•by a Certifteatc"o Conq,liance(yes or nu):_(attach a copy of certificate) Dimensions: 6 3— Sludge deptl►: B > Distance[rots►Iup of sludge Iu bunun►of outlet Ice of bafllc: S / Scwn thickness: 0 Distance from top of stunt to toll of outlet tee or baffle: Distance born button,of scum to butium of outlet tee or ball) 1 r flow were dimensions determined: 0 -T d;.X Cununenls lull pumping recun►menda►iuits,u,let and outlet tee or barlle condition,sttuctu,at intcipily,liquid levels as rclaled to outlet invctt,evidence of leakage,ett.): s Aa GREASE TRAP._(locate un site t art) ' Dcpth bcluw grade: hlalcrialOfconswetion:_toll cte _n►elal fiberglass`pulycthyla,c _other (explain): — Dimensions: �curn thickness: Distance from lop of stunt u lull of outlet tcc or baflic:_ Distance[toll►button,of cunt to buttwn of outlet lee or bafllc: Dale of last pumping: Collunents(on pumpi g recunu»endatiuns,inlet and outlet ice or bafllc cunditloa,structural imcgity,liquid Imls as related to outlet i 1•cll,Uiticncc of leakage,etc.): 7 Page 8 of I I ...}..� a s .^�. .�.j.. ?c:�'. , a. t • . °„ s .4x a •' OFFICIAL INSI'LCCION F0161—NOS' jI"OIt VOLUN:"I'Aitl' ASSL;SSAIEN'i S SU'BSUKFACL SEWAGE DISPOSAL SYSTLKINS1'EC17ION 1.0101 SYSTEM INFORMATION(continued) ` rroperly Address �!, G Ft,i�-S 11 t z r1'L i Li :;1r� Owner: L..I`nib 1� } t S Dale of lnspcctlon � G — TIGHT or HOLDING TANK: •� ' (►atilt must be pungrcd at till"of inspectivn)(lucate on site plan) ' Depth below grade: + Material of construction: onctc►e_metal_fiberglass jluly°llsylcne o►lier(explain): Dint"nsions: - Capacity:Ti-uinptn gDesign flgallunslday AI arm reVAlarm Icv svutkin orderDate of lag (J'csurnuCuttuncntnd float s%vitchcs,ctc.): T DISTRIBUTION BOX; _____(tf prescnt must be opcncd)(locatc.oit site 1►1an) Depth of liquid level above outlet invert: C)Callullc + IcaUge nls(Hole if box is c1c. and JisUibu(ivn to ouilcts equal•arty'evidence of solids carrp^ovcr•arty evidence of IcakaSc into or out of bolt,etc.): ' i I'UI11P CIIA111BLR: •(locate on site plan) - Nino in working or Cr(ycs or no): Alarms in working rdcr(ycs or no):— Conunents(riot" ondition of pump chamber,condition of pumps and appurienan(es,Etc.): • , a r Page 9 of I l OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C R SYSTEM INFORMATION(continued) Property Address: Owner: Date of inspection: SOIL ABSORPTION SYSTEM(SAS):_�� (tocate on site plan,excavation not required) If SAS not located explain why: ��hing pits,number leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOO/da ( sspool must be pumped as part of inspection)(locate an site plan) Number ananon: Depth—toto inletinvert: Depth of sr.Depth of sr:Dimensionool:Materials oction: Indicationwater inflow(yes or no): Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loc eon site plan) Materials of co traction: Dimensions: Depth of so 'ds: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C 3 g SYSTEM INFORMATION(continued) Property Address: t(0 k 511 '71 1 C Owner: C_-•� ��t � Date of Inspection: F a 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. V' 11....77 t N 1 10 i , f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: Owner. b-i' N C=•6 i--\Z,C- . Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: qbtamed from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobservation hole within ISO feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must de?s *be w grou d wey er elevation: da P M i ll I Town of Barnstable p THE Tp�� yP Regulatory Services IARNSTAHLE. ; Thomas F. Geiler,Director MASS. a 1639. Public Health Division ATEp Mp'�A Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTICTisclainner Private Septic Inspections.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS WIN DEPARTMENT OF ENVIRONMENTAL PROTECTION W TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Harbor Village Property Address: 160 Marstons Ave.Unit 15 Hyannisport, MA Owner's Name: Nick Bishop Owner's Address: 200 Pleasant St. FraminghaW, MA Date of Inspection: Name of Inspector:(please print) William E_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: ( 5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant:to Sec 'on 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: r L Date: K-,2 - 6 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaWor DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I 4 Page 2 of I 1 f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Marstons Ave. Unit # 15 yannisport Owner: Bishop Date of Inspection: — - Inspection Summary: Check A,B,C,D or E/,ALWAYS complete all of Section D VO3 Passes: e not found any information which indicates that any of the failure criteria described in 310 CMR 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaiil ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ansm er yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please expl The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exis ing tank is replaced with a complying septic tank as approved by the Board of Health. *A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance Min eating that the tank is less than 20 years old is available. D explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will ass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed D explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:160 Marstons Ave. Unit #15 Hyannisport Owner: B i s op Date of Inspection: 16 s;� —4 ir C. Further Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health,safety or the environment. 1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy tem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. -- 2. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 rface 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 front 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 ; OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM PART A CERTIFICATION(continued) Property Address160 Marstons 'Ave. Unit #15 yannisport Owner: Bishop Date of Inspection: X-J--8 D: System Failure Criteria applicable to all systems:. Yo must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Large Systems: e considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g Y u must indicate either"yes"or"no"to each of the following: { e following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary.to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well . If ou have answered"yes"to any question in Bettina E the system is considered a significant threat,or answered "y s"in Section D above the large system bas failed.The owner or operator of airy large system considered a s' nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 5.304.The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 Mars tons Ave. Unit #1 5 Hyannisport Owner: Bishop Date of Inspection: e•-�- Uri 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 1/ Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? - Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? -. Were all system components,excluding the SAS,located on site .9 _ 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: L o / Existing information.For example,a plan at the Board of Health. t/ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Marstons Ave. Unit #15 Hyannisport Owner: Bishop Date of Inspection: 6-.7- —0 t FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): • DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedroom's): Number of current residents: .fs Does residence have a garbage der(yes or no): Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected(yes or no):" Seasonal use: (yes or no):_ Water meter readings,if available(last 2 years usage(gpd)): A Wired w;4 ter Sump pump(yes or no): A,0 Last date of occupancy: COMME /ank ND STRIAE Type of estnt: Design flo o 310 CMR 15.203): gpd Basis of de (seats/persons/sgft,etc.): Grease trap (yes or no): Industrial ding tank present(yes or no): Non-sanita discharged to the Title 5 system(yes or no): Water metgs,if available: Last date ocy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records i Source of information: lJZ A n r'0 c.f, Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, innsstaI d(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):_ 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave Unit 415 Hyannisport Owner: Bishop Date of Inspection: s_ 1—d BUILD G SEWER(locate on site plan) Depth belo grade: Materials f construction:_cast iron _40 PVC_other(explain): Distance om private water supply well or suction line: Comme s(on condition of joints,venting,evidence of leakage,etc.): /(locateSEPTIC TANK: on site plan) ' , Depth below grade: 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: s d Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /�oZ , • , , Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle.condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ J �--� C ,4 ` 96 GREA E TRAP:_(locate on site plan) Depth be ow grade:_ Material f construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thi kness: Distance from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Co nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rely d to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 l ; OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave. Unit #15 Hyannisport Owner: Bishop Date of Inspection:,"— -6 TIG Tor HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth low grade: Materia of construction: concrete metal fiberglass_polyethylene other(explain): Dimensi ns: Capaci gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date f last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z/ if resent must be o ened (locate on site plan) ( P P ) 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.): ' 0 1 PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): F Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave.. Unit #15 Hvannisport Owner. Bi shoes Date of Inspection: 6,7—Z> SOIL ABSORPTION SYSTEM(SAS): �ocate on site plan,excavation not required) If SAS not located explain why: Type / leaching pits,number: (✓ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): G G2 v l L C POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numb r and configuration: Depth top of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimens ons of cesspool: Materia of construction: Indicati n of groundwater inflow(yes or no): Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Mater als of construction: Dim nsions: De h of solids: ' Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave. Unit #15 yannisport Owner: Bishop Date of Inspection: �a 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. } I d' U Ll 1b vt a v 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Marstons Ave. Unit #15 Hyannisport Owner. Bishop Date of Inspection: d°-2--0 7 SITE EXAM Slope Surface water Check cellar f Shallow wells Estimated depth to ground water L2-feet Please indicate(check)all methods used to determine the high ground water elevation: 9btained from system design plans on record-If checked,date of design plan reviewed: ,/Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you a tab ished the high ground water elevation: 22! 5 l Al6A,' ,s' i9 w 11 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re R 34229 9/2/2013 required for every P Y page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. ICI Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/2/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ` ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. � d �/► 3Sa� t5ins•3/13 Title 5 Official Inspection Fo b urface Sewage Disposal System•Page 1 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM- POOR QUALITY ORIGINALS) IMA 7��"w C&' I: DATA ^ j f f3 H s Posta s S certified F i CV :Postmark Retum Receipt Fee �tfere i ) r�1St�bl� I t . 7 (Endorsement Requite t 4� i Barnstable 7 `y Restricted Delivery Fee ^ (Endorsement Requited) \ Services. �� A&�IrrlaieatSi :2 Total Postage&Fees $ I' 11.1 vSent To Vincent Cardilloilic Health Division Stteet,ApENo.;-"".. 1164 Beachcomber Court in Street, Hyannis MA 02601 Osprey FL 34229-9702 t or Po Box No. City State.Z1P+4 l r Thomas k McKean.CHO CERTIFIED MALL#7012-1010-0000-2848 -1506 April 8, 2013 l VINCENT CARDILLo 1164 BEACHCOMBER COURT , IMPORTANT NOTICE OSPREY, FL 34229-9702 Map &Parcel: 288-180 — OON Map &Parcel: 288-.180— OOP The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic- system. This letter-directs you to connect your dwelling, at 160 Marston Avenue, Hyannis,MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PE32'ORDER O THE BOARD OF HEALTH p omas . McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWI connectlletters Stewart Creek Sewer ConnectslMA1UING LetA Sewer 2Pa Merged 3-28-13 Yi?015.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every re 1164 Beachcomber Ct/OsP Y FI 34229 9/2/2013 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 160 Marston Ave Hyannis is served by a shared Title V septic system consisting of 2000 gallon septic tank, distribution box and 4 precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this property has been ordered to connect to town sewer on or before 3/30/2015. ( see attached) B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every P Yre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every p yre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, ,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every p yre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every er pre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and 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): 10 Number of bedrooms (actual): 10 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1100 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re A 34229 9/2/2013 required for every P Y page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every er pre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1 Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re FI 34229 9/2/2013 required for every P Y 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 4feet 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: 2000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re FI 34229 9/2/2013 required for every P Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" 3 Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every p yre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: .gallons 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re FI 34229 9/2/2013 required for every p y page. Citylrown 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,l 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re FI 34229 9/2/2013 required for every P Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 4 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of past hydraulic overloading Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer, Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Ospre FI 34229 9/2/2013 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is 1164 Beachcomber Ct/Os re FI 34229 9/2/2013 required for every p Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC �U SYSTEM INFORMATION(continued) i{ Property Address: — Owner Date Of Inspectiow -! OF SEWAGE DISPOSAL SYSTEM: include ties to at least two Permanent references landmarks or benchmarks locate all wells within 100' t f � /\1 DEME TO GROUNDWATER �a to Voundwater. L:-f feet metbd of determination or approximation: /L (revised 11/03/95) 9 1 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every 1164 Beachcomber Ct/Osprey FI 34229 9/2/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: i You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 160 Marston Avenue#16 Property Address Vincent Cardillo Owner Owner's Name information is required for every p yre 1164 Beachcomber Ct/Os FI 34229 9/2/2013 page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDYCOXE Secretary ARGEO PAUL CELLUCCI DAVID B. TRUHS Governor Cortiuiussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A T .may CERTIFICATJPN � Property Ad tress S j�r � �� Name of O.:?O VI.{(T *k �V'+j Address of Owner: Z66 INM f 49 �+ Date of Inspection: i .'9' Name of Inspector:(Please Print) l-p • trIAt 1 am a DEP owed s em inspector rsuarrt to Section 15.340 of Title 5(310 CMR 15.000) i Company Name: IROW In '~r� Marling Address: 1211 Telephone Number: 0222 C2 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se a disposal systems. The system: Passes Conditionally Passes _ Needs Furth r Eva //luation By the Local Approving Authority r tsr Fails Q Inspector's Signar - Date: �O 15 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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. NOTES AND COMMENTS I 5F GTIOL•_.) &OL4�T14�1 S Y � s�T7csF�.c-7a�2r �� 6�= Al�GTI ate/ Fbew P;ZD. revised 9/2/98 Pagel of11 401 Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 nil► e bL4tG W&I UwTr -* 1. Owner: �74t�4`v51 Date of Inspection:--ilit-4 F. INSPECTION SUMMARY: Check A, B, C, or D: A. :SYS ASSES: 1 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria,p9t valuated are indic ed below. COMMENTS: aF P (�� 7 B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup 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). broken pipe(s)are 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 i revised 9/2/98 Page 2of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: KtAtIbTD45 IWE, 0647 -4 1 C. Owner: lr Date of Inspection: 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 IN ACCORDANCE WITH 310 CMR 15.303 111►(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property address: l i60 UW245 b4S 1 J Nff"* 16 Owner: Date of Inspection:5 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described 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. Yes _✓✓ Backup of sewage into facility-or system component due-to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ��. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _✓/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s): umber of times pumped_. Y Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. 4, 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. YE Any portion of a cesspool or privy is within 50 feet of a private water supply well. / * r 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 anaiysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow,of 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: Yes No the system is within 400 feet of a surface drinking water supply i the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30.4(2). Please consult the local regional office of the Department for further information. revised 9/2/98 P2ge4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: �DJr/CAL, Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. 4jy*Wt5j None of the system components have been pumped for at least two weeks and-the system has been-receivirtgimrmal 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 o ained annd�examined. N to if they are not av ilable N/A. _ The facility or dwelling w s inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. . / The size and location of the Soil Absorption System on the site has been determined based on: 9� Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) ✓/ _ The facility owner(and occupants,if different from owner) were provided with information on the proper.maintanance-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION Property Address: ILO, Vl e%i W.'� AYE04n lb Owner:Date of Inspection: 615 Iqcf FLOW CONDITIONS RESIDENTIAL: M Design flow: `/V g.p.d./bedro m. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow ZOO `�.+�Number of current residents: -4C Garbage grinder(yes or no):,e� L, Laundry(separate system) (yes or no#b; If yes, separate.inspection required Laundry system inspected es r no) Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): tk "t4 L 12DO �j ��j �` G�-• Sump Pump (yes or no): t '� 01-1 Last date of occupancy A1/ I�'v V COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING OR"OFRD� so e f information:!S �01V/ C4q71804-. ystem pumped as part of inspection:(yes or no) 1 If yes, volume pumped: gallons Reason for umping: �i t�u►1�tk.lt,� �Y Qc�gtw�oti.� -SQAz'1G TYPE 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIIM x AGE of all components, date installed Of known) and source of information: — IATE VA.CT -?IVjHfif 4J02;K. 1pef Sewage odors detected when arriving at the site: (yes or no) O revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 0 Property; :: 1(00. Y+�WQ.ST�wl.S CT' 1 Date of Inspect�xr BUILDING SEINER: (Locate on site plan) Depth below grade: 1z_ Material of construction:_cast iron 40 PVC_other(explain) Distance from private ate supply well or surti'n line Diameter# 1�� u �•# b �r Commen s:ri 'nditi n of joint venting, evidence-of leaka e,etc.) , W SEPTIC ANK: (locate on site plan) Depth below grade:/ Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ .Is-age confirmed by Certificate of Compliance_(Yes/No) Dimension`1 r&r,X O k 6-7 Sludge depth: L I �t ' Distance from top of sludge ^to bottom of outlet tee or baffle: p ic> EY 1 d� �� Scum thickness:_ IL. i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and out tees or baffles, depth of liquid level in relation to outlet invert, structuraFi tegrity, evide ace of lea ge, etc.) jw G I! GREASE TRAP: (locate on site plan Depth below grade:_ Material of construction:_concrete metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; IGO U�i%67bt�5 AYES LX,4T *t� n Ower: * �� y Date of Inspection: t5�(�* TIGHT OR HOLDING TANK:14.(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert:, Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) tD / a / 0 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.) revised 9/2/98 Page 8of11 4 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C M/ SYSTEM INFORMATION(continued) Property ess: (� . � �Y V� 1 ��p Owner: Date of Inspection: V5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: L Type: leaching pits, number:_— O • �J ` �{1 leaching chambers,number: leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: , overflow cesspool,number:_ � �• �. o �L1��1L Alternative system:Name of Technology: Comments: (note c itO of soil, Sig s of hydraulic failure, level of ponding, dam oil,yWdition of vegetation, etc.) CESSPOOLS:NA (locate on site plan) Number and configuration: Depth-top of liquid to inlet invent: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: y Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY:4 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9orn I - 4 � v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y�SYSTEM INFORMATION(continued) Property Address: 1(� W� .5"Cl5 'C , L%-A Tr 4 1 G Owner: �} Date of Inspection: ti •�C/aCj SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3� i �1 0 41t1r-%4 C bqqA&C 8D f;VFD. -DOES h/07 67?COF7c - �r,)OA.1 7-7 cvAlc1`/ s � -M w ter- VA1 7. revised 9/2/98 Page 10or11 I L. r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ',1 SYSTEM INFORMATION nu ��RMATION(continued)Pr Property A ess: ' wl��W,> Owner: � / Date of Inspection. NRCS Report name 'L wK.11 $ �1� (,'� Cf,>U Soil Type_ e%lee GO 6 : Typical depth to groundwater Arm USGS Date website visited Observation Wells checked V1W2;P **7Ajj,-3.e1p'e- ,2 Groundwater depth: Shallow Moderate 1/ Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwat iteet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) V Determined from local conditions Checked with local Board of health Check FEMA Maps Checked pumping records +� Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) eon `r revised 9/2/98 Page 11of11 � I 1 COM-MON-WEALTH OF MASSACHL;SETTS E�iECt TIVE OFFICE OF E:�'VIRO\;1iE\TAi AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE ICI\TER STREET. BOSTON KA 0210c 1617) 292-550u TRL DT COX-- Secretary ARGEO PAUL CELLLCCI DAVID B STP.:'HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Harbor ,Tillage CERTIFICATION Property Address: 160 Marston,1Ave . TJnit 1 r�Name of owner Nancy Frangione Address o Owner: Date of Inspection: - Name of Inspector: (Please Print)Wm. E . Robinson Sr. 1 am a DEP approved systeM inspector rsuartt to Section 15.340 of Title 5(310 CMR 15.000) CornpanyName: Wm. E . Robinson Septic Service_ Mailing Address: PO Box 0 9, Centervill�iVlA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: L Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails � Inspector's Signature: I, Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 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. NOTES AND COMMENTS nFB� �000 revised Page Iof11 i• ••!ed on Recvclyd Panr, a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Iroperty address: 160 MarstonAve . , Hyannisport Unit 17 Jwner: Nancy Frangione Date of Inspection: INSPECTION SUMMARY: Check (A, 18, C, of D: A. SYc✓ PASSES: 1 have not,found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board'of Health, will pass. Indicate yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup 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). broken pipe(s) are 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Prop"Addresslb0 Marston Ave , Hyannisport Unit 17 Owner: Nancy Frangione Date of Inspection: 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 W ACCORDANCE WITH 310 CMR 15.303 0)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER , revisea� Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Marston Ave . , Hyannisport Unit 17 Owner: Nancy Frangione Date of Inspection: ^ A o D. SYSTEM FAILS: You st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will bP necessary to correct.the failure. Yes o Backup of sewage into facility-or system component due to an overloaded orelogged 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 112 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 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 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. 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. LAR E SYSTEM FAILS: You must ndicate either "Yes" or "No" to each of the following: he following criteria apply to large systems in addition to the criteria above: he system serves a facifity with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public ealth and safety and the environment because one or more of the following conditions exist: 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) Th owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offic of the Department for further information. revised 5%2/9B Paec4or11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART 8 CHECKLIST Prope<ty Address: 160 Marston Ave . , Hyannisport Unit 17 Owrw: Nancy Frangione Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yew No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least 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. _ The facility-or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. 1/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ]L _ Existing information. For example, Plan at B.O.H. _ Determined_in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / 11.5.302(3)(b)1 _ The facility owner(and occupants,if differeru from owner) were provided with information on the propernmintenaacs f SubSurface Disposal Systems. .e:'ised 9j2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION sroperty Address: 160 Marston Ave . , Hyannisport Unit 17 Owner: Nancy Frangione Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:IG 7e g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow b 0 Number of current residents: r� Garbage grinder lyes or no):40 Laundry(separate system) (yes or no):/&6; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):-4L-'1-< Water meter readings, if available (last two year's usage(gpd): Central Water Sump Pump(yes or no): Yo Last date of occupancy:L✓- COM ERCIALflNDUSTRIA7LL: Type establishment: Design low: qpd ( Based on 15.203) Basis of design flow Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-sen' ary-waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da a of occupancy: OTHER (Describe) Last da of occupancy: GENERAL INFORMATION PUMPING RECORDS an source of infolmation: ��y��1 2:- 12 System pumped as part of inspection: (yes or no)-ft,0 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM y 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) f� I/A Technology etc. Attach copy of up to date operation and maintenance contract jS 06f Tight Tank Copy of DEP Approval + Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/GE Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " SYSTEM INFORMATION(continued) *roperty Address: 160 Marston Ave . , Hyannisport Unit 17 owner: Nancy Frangione Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of ants, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) 1 ) Depth below grade: Material of construction:_ oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_ (Yes/No) Dimensions: 'y— '� /3 1 Sludge depth: I r Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_ , Distance from top of scum to top of outlet tee or baffle:Distance from bottom of cumto bottomof outlet t e or baffler How dimensions were determined: Joe A— L 'omments: (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.) 9-6 ab n b/ r GR E TRAP: floc at on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal Fiberglass _Polyethylene_other(explain) Dimen ions: Scum ickness: Distan a from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Com ents: (rec mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid nce of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION fcorrdrwed) J,rop"Address: 160 Marston Ave,.-, Hyannisport Unit 17 Owner: Nancy Frangione Date of Inspection: `7-0--� TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ P Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alarm evel: Alarm in working order: Yes_ No_ Date f previous pumping: Cc ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: .,,/ (locate on site plan) Depth of liquid level above outlet invert:` Comments: (note if level and distribution is equal, evident@ pt solids carryover, evidence of leakage into or out of box, etc,) - � Id(` PUMP AMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms i working order(Yes or Not Comme ts: (note c dition of pump chamber, condition of pumps and appurtenances,etc.) revises 5/2/98 Page 8of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cort hued) top"Address: 160 Marston Ave . , Hyannisport Unit 17. Owrwf- Nancy Frangione Date of Inspection:" SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type. leaching pits', number: leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number._ Alternative system: Name of Technology: Comments: ' Inote condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) GJ S )o a _CESSP LS:_ (locate o site plan) Number a d configuration: Depth-top f liquid to inlet invert: 7epth of s lids layer: )epth of s um layer- Dimension of cesspool: Materials o construction: Indication f groundwater: i flow (cesspool must be pumped as part of inspection) Comore s: lnote c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Material of construction: Dimensions: Depth of solids: Comore ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) a Ye` vise 9 2 7 Peer 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "roperty Address: 160 Marston Ave . , . Hyannisport Unit 17, Jwner: Nancy Frangione Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks _.. locate all wells within 100' (Locate where public water supp mes,into house) 1� lie, revised 9;2/98 Page 10of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) top"Address:160 Marston Ave . , Hyannisport Unit 17 Owner: Nancy Frangione Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater L,:rFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 'Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) LS �7cJ L Z�� /Q3'0• revised Page 11of11 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK Address of property Harbor Village Unit..�17 160 Marston . ve annis or Owner's name Mr Dawson Date of Inspection May 13-1995 PART A MAY 2 2 1995 CHECKLIST '~ HEATMDM. =CF BA ` LF�ST�B F 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 at least 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. The facility or dwelling was inspected for signs of sewage back-up. V The site was inspected for signs of breakout. . _1Z All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 7J/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. e 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms .1_1) number of current residents -XjL garbage rind g grinder, yes or no laundry connected to system, yes or no .ir seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information . System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty 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) ' Other (explain) ` g �I��t,r� i �� Approximate age of all components. Date insta information: lled, if known. Source of Al, Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK (locate on site plan) depth below grade: I 1 material of construction: °' concrete metal FRP other(explain) C . l i dimensions: O sludge depth O distance from top of sludge to bottom of outlet tee or baffle 0 scum thickness 0 distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: ✓ (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER:�� (locate on site plan) 1 pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, . recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not re approximated by non-intrusive methods) required, but may be If not determined to be present, explain: Type. leaching pits and number ., L leaching chambers and number �� If O 0 0s E°-k-% �,a K04 leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic .failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) /Iry PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, ` condition of vegetation, recommendations for maintenance' or repairs,etc. ) 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks to a all wells within 100 , LO � / 0 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: L. 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Al Static liquid level in the distribution box above outlet invert? _ Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? _ Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supple water supply? or tributary to a surface _k1 within a zone I of a public well? IV— within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? Al 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 analysii . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Wm. E. Robinson Company Name Wm. E. Robinson Septic Service Company Address P.O. Box 1089 Centerville MA 02632 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. !Vk" one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies .to: Buyer (if applicable) Approving authority i COMMONWEALTH OF MASSACHUSETTS - ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r i D`) DEPARTMENT OF ENVIRONMENTAL PROTECTION r - 4f9p TITLE C 111 L J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME f pT"e�E SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Harbor Village 9 Mars tons Ave"*%Hyannisport 'Q Owner's Name: Chris Babcock MAP @� Owner's Address: - PARCEL . g.s ®b tS Date of Inspection: Z 'LOB Name of Inspector:(please print) Wi 1 1 jam E .Robinson Sr. Company Name,: William E. Robinson Septic Service Mailing Address: P OA-Box 1089 Centerville', MA Telephone Number: ( 5081 _ 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true,accurate and-complete as of the time of the inspection.The inspection was performed based on my training.and experience in the proper function and maintenance of on site sewage disposal systems.1 am a.DEP approved system inspector,pursuant to Section.15.340 of Title 5(310 CMR 15.600)_ The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or bas a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I t Page 2 of I l : OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INS PIECT 4 FORM PART A CERTIFICATION (continued) Property Address: Harbor Vill P #J_ 160 Marstons nisport Owner. ris Babcock ` Date of Inspection: Inspection Summary Check A,B,C,D or E I ALWAYS complete all of section D A. Syste Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments:.- B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or' repair .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. m the for the following statements.if"not determined"please Answer es,no or not determined(Y,N,ND)i explain. septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally un sound, xhibits substantial inf ltration or exfiltration or tank failure rs imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board`of Health: •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND exp a'in: bservation of sewage backup or break out or high static water level in the distribution box due to-broken or obstru pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approva of Board of Health):- broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND exp ain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is nmovcd ND explain: I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Harbor Village #1 9 160 Marstons Ave Hyannispor.t.. _. Owner: Chris Babcock Date of Inspection: G 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 fail'n to protect public health,.safety or the environment. 1. stem will pass unless Board of Hea'h'determines inaccordance with 310'CMR 1:5.303(1)(b).;that the` s stem 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 SO feet of a bordering vegetated wetland or a salt marsh 2. Sy tern will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the system saunc1 oning 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 sur ace 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has aseptic tankard SAS and the SAS is less than 100 feet but 50 feet or more front a p ivate water supply well".Method used to determine distance •• his system passes if the well water analysis,performed at DEP certified laboratory,for coliform bac eria and volatile organic compounds indicates that the well is free from pollution from that facility and, the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. Oth r: 3 , Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -------------- Owner. Date of Inspection: D. System Failure Criteria applicable to all systems: You� ust indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS"or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clo ed SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS o�` cesspool _ Liquid depth in cesspool is less than V below invert or available volume is lessthan'/: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. 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 l 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 1b0 feet.but greater than 50 feet from a private water supply well with no acceptable water qua lityanalysis.[This system passes if the well water a1. nalysis, performed at a DEP certified laboratory,for.coliforrn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to.or less than.5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. arge Systems: To b 'considered a large system the system must serve.a facility with a design now of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (The ollowing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary.to a sm-face 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 yo 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 famed.The owner Operator of any large system considered a signi leant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3 4.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Harbor Village #1 9 160 Marstons Ave Hyannisport _ Owner. Chris Babcock Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health' Were any of the system components pumped out in the previous two weeks? /Has the system received normal flows in'the previous two week period ✓Have large volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A ✓_ Was the facility or dwelling inspected for signs of sewage backup? �✓_ Wasthe 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 inforTmation 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 _ _L11 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 approximationof distance is unacceptable)[310 CUR 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION FORM r NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Harbor Villa e #19 Property Address: g - 160 ars ons AVe Hyannisport Owner: ris Babcock Date of Inspection: —4 FLOW CONDITIONS RESIDEN'TUL Number of bedrooms(design)-.JQL Number of bedrooms(actual): DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x N of edrooms): Number of current residents: Does residence have a garbage ' der(yes or no):4 Is laundry on a separate sewage system(yes or no): 0[if yes separate inspection required] Laundry system inspected(yes or no):' u Seasonal use:(yes or no): S Water meter readings,if a aila`ble(last 2 years usage(gpd))" :� common water system Sump pump(yes or no):�✓ Last date of occupancy:: CO MME CIAL/INDUSTRIAL Type of es blishment: Design flo (based on 310 CMR 15.203): gpd.. Basis of design flow(seats/persons/sgft,etc.): Grease tra, present(yes or no): Industrial aste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ - Water eter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �/19 G `9 e7 59 01 —per Was system pumped as part of the inspection(yes or no):A,4) if yes,volume pumped: gallons--How was qua¢�itypumped determined? Reason for pumping: i+�" TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _PRIVY _ hared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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): Approximate age of all components,date installed(if known)and source of information: �C, Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued): Property Address: Harbor Village #1 9 160 Marstons Ave Hyannisport Owner: Chris Babcock ..... . . ..... Date or Inspection: 3—3 O 3 BUILDING SE R(locate on site plan] Depth below grade Materials of cons ction ` `cast iron _40 PV.0 ._other(explain): Distance from pri ate water supply well or suction line: Comments(on ondition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) 1 Depth below grade: _ Material of construction: l�concrete—metal_fiberglass—polyethylene other(explain) If tank is metal list age:_ Is age confu-med•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:_�D Scum thickness:' Q` Distance from top of scum to top of outlet tee or baffle: 07 Distance from bottom of scum to bottom of outlet tee or baffle:r�� How were dimensions determined: C')0 u"✓L.5 ........... . Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,ev �,etc.): GREASE P: (locate on site plan). Depth below ade:_ Material of co truction:—concrete_metal_fiberglass_polyethylene_other = (explain): Dimensions: Scum thicknes Distance from op of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last p ping: Comments(o pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to utlet invert,evidence of leakage,etc.): 7 pages of I 1 OFFICIAL INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM' PART C SYSTEM-INFORMATION(continued): Harbor Village #19 Property Address: ars ons Ave Hyannisport Owner: ris Babcock Date of Inspection: 5 ' O 3 TIGHT HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo grade: g ____polyethylene Material of nstruction: concrete. metal fiberglass other(explain): Dimensions: Capacit): allons Design Flo gallons/day Alarm prese it(yes or no): Alarm level Alarm in working order(yes or no): Date of las pumping: Comment (condition of alarm and float switches,etc.): DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: q y RY evidence of ..'`. Comments(note if box is level and distribution to outlets equal,an evidence of solids carryover,any leakage into or out of box,etc.): ® y� PUMP C MBER• (locate on site plan) Pumps in w rking order(yes or no): Alarms in corking order(yes or no): Comments note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Harbor Village #19 Property Address: ,6O ens—;Tve Hyannisport Owner: etlr±5 Babcock Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type leaching pits,number:_3 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSP LS: (cesspool must be pumped as part of inspection)(locate on site plan) Number an configuration: Depth .top f liquid to inlet invert: Depth of so] s layer: Depth of scu n layer: Dimensions of cesspool: Materials of onstruction: Indication of groundwater inflow(yes or no): Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Material of construction: Dimensio s: Depth of olids: Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 or 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION'(continued) Property Address: Harbor village #1 9 Ave Hyannisport Owner: G ��k Date of Inspection: .—o 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. g P® JE 10 Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Harbor Village #19 IbO ars o s Ave Hyannisport _ Owner. cnris Babcock Date of Inspection: 3-3,0'3 SITE EXAM Slope Surface water Check cellar / Shallow wells tG Estimated depth to ground water J,40f,et Please indicate(check)all methods used to determine the high ground water elevation: 11btained 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: h.S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: .r You must describe how you es b ished the high ground water.Slyvation: 14 1 OLD u D 'M 11 160 --19 Ma;rston Avenue l Hyannis 'P A =' 288 18000S- -- - - - -- I No. 4210 1/3 FEE o' (9 10% 0 0 a Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Weld Trudy Coxe Governor Srutlary Argeo Paul Celluccl David S.Struhs u.G"rw ComndMiorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L+2 O /-9(/ C— PART A - y9y//'I/ S �ar7� yo20 CERTIFICATION Property Adder /N e r�a Go. �9 Address of Owner. Date of Inspection: (If different) h✓`} Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 'V passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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: Check A,B, C,or D: A) SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR. 15.303. Any failure criteria not evaluated are indicated below. B) TEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inepection. Indicate ,no,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 exflltmtion,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 4 1 ice,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l 676 /nerstAs .i3(/e— d/y�4h�ris �� 1-n L/ r^DtJ Cc/%o �-- Owner. A e o R et en/k Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution boa 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): broken pipe(s)are replaced obstruction is removed distribution boa is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(*). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl THER 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 lic health,safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND AFETY 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 within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply 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 eoliform 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 feu than 5 ppm. 3) OTH AA, (revised 11/03/95) 2 f � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J L9 O M4 i"S 1d AI S Owner. /'�d h Date of Inspection: D YSTEM FAILS: I ban 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 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 1/2 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 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 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. 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. El LARGE SY TEM FAILS: The flowing criteria apply to large systems in addition to the criteria above: The m serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public 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 rator of any such system shall bring the system and facility into M compliance with the groundwater treatment program requirements of 14 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 f, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '0 dL 0 PART B CHECKLIST Owner. pVf Ra 017/L'lt Date of Inspection: Check if the following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. _ one of the system components have been pumped for at least 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. 2As built plans have been obtained and examined. Note if they are not available with N/A. `The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. _v 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. 'he facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surf we Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + 0 PART C f" SYSTEM INFORMATION Property Address:- Owner. Date of Inspection:`1 �_g FLOW CONDITIONS RESMENTIAI: Design flow: ® allono Number of bedrooms: Number of current residents: 0 Garbage grinder(yes or no):� Laundry connected to system(yes or no): Seasonal use(yes or no): Water meter readings, if available: r'1 j a %�t Id VV'. el Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of formation: G ye•rLI Jea 9 System pumped as part of inspection: (yes or no)—Ar-'C If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tanWdistribution box/soil absorption system Single cesspool Overflow cesspool svy Shared system(yea or no) (if yes,attach previous inspection retards,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: /=b A Sewage odors detected when arriving at the site: (yes or no) Gl (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 74 Property Address: J& 6F Owner. &4 h 1-�Ltvn rc/L Date of Inspection: 4, lq SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:—concrete metal FRP_other(explain) Dimensions: 6 4; `r 7 6 1 Shulge depth: / , Distance ��f7room��top of sludge to bottom of outlet tee or baffle: / � Scum thickness: 0 Y 1 Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: / Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in let' to outlet invert,structural integrity, evidence of leakage,etc.) G o% Q C® � 6�•N t"s °4 1�e)� ha s G E TRAP: (loca n site plan) Depth bel w grade: Material o construction:_concrete_metal_FRP_other(e:plain) Dimensions Scum ess: Distance top of scum to top of outlet tee or baffle: Distance bottom of scum to bottom of outlet tee or baffle: Commen (reoomm dation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, eviden of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Aaareee: l(n D rn sirs)�n� �U�. 1YA17nis/✓ort" Owner. Date of Inspeetion:L` TIG R HOLDING TANK.— (loco on . plan) Depth be Material of n:--concrete_metal_FRP_other(ezplain) Dimensions: Capacity. one Desiga flow: ons/day Alarm level: Comments: (condition of' et tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) .&Q PUMP C BER:_ (locate on ' plan) Pumps in rking order:(yes or no) Comments• (note co n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) °c/g Property Address: I10 6 n44-rS 7O .$ /�� Owner. fj R u dh/C-<_ Date of Inspection:,q_;L Q_o 1, SOIL ABSORPTION SYSTEM (SAS):_✓ (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,condition of vegetation etc.) LESS LS:_ (locate o site plan) Number an configuration: Depth-top o liquid to inlet invert: Depth of so layer. Depth of layer: Dimensions f cesspool: Materials construction: Indicatio of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.) PRIVY: (locate on plan) Materials construction: Dimensions: Depth of so Comment.:(n -condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM U PART C �� r SYSTEM INFORMATION(continued) �41� Property Address:- Owner. Date of Inspeotion: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 36 1 DEPTH TO GROUNDWATER Depth to groundweter:_LL�_feet _ _ ` method of determination or approximation: IJ G I t S ! I',o k S f (revised 11/03/95) 9 NO................_....... Fss......3.5.............. ..THE CO&'rMG;QWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable ...........................................OF Allp irFa#ion for Uispoii al Morks Tnnutrur#iun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal SystemHrbor Village Condominiums Units 3, 4,59 6 & 7 ...--•-••-------................................................................................. ----•••------------•--•-...._......_._.....--------...--••--------............................--•- Location-Address or Lot No. 8nna]A.S_&..Budnis:1c.............. _,Maxl __$ x�. * Ya1rluh� � 02673......_ Owner Address W Installer Address U Type of Building Size Lot.....15e8_•aCr@• q, feet Dwelling X No. of Bedrooms___...13.................................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building 5_..bldgs_........... No. of persons........26............... Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------• . W Design Flow........``JS...............�; ......gallons per person per day. Total daily flow-1430----.............................gallons. IxSeptic Tank—Liquid capacity ..gallons Length----15...... Width6 "'...5��..._ Diameter__ """'. Depth_..6'... I.#. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.._......--.._......sq. ft. Seepage Pit No._4_-pats---- Diameter.._..19'1._..... Depth below inlet..._6�....._..... Total leaching ar4196941l!t".it. Z Other Distribution box ( X) Dosing.tank ( ) aPercolation Test Results Performed by._pXl- --- Date.._FebTi]STy_•1%...1982 Test Pit No. I.....2........minutes per inch Depth of Test Pit....1........... Depth to ground waternMS...enemuntered G=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ -----------_----------------------------•-•----------------------------•-------------•---------•------------------------------------ •-----------•-•- ----- Description of Soil---------- ©3�X. 2pso.�l....sandy.gjubs!il, meiYa-. •-•_-_ U .....••-••••••••-•-•-•••-•-••••••••----•......•-••••.....••••••-•-••••-••••••••-•...••----•-•••---••-•--••-•••••••••.............•••••......••-- W -------------------------------------------------------• ----------------------------------------------------------------------------------------------------------------------------------------•_.._. U Nature of Repairs or Alterations—Answer when applicable..____UP9rade_-q?4 n9__sy§ e111 -------•-----------------------------------------------------------------------------•...---------------------------------------•----------------------•---------------------•--•--•••...---•-••-••-•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'Tt 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certifi to of Compliance has �n issued by the board of health. r — -z. ---- ------- J Date .Application Approved By------ •-•'-• --• . . ••-•-•......-•......... � 2--6 Date Application Disapproved for the following reasons------------------•--------------•--------------------------------------------------------------------....._..--- --------------------------------------------•-----•--------------------------•---------------------......--------------------•---------------------------------------------------.........••-•-•......-- Date PermitNo......................................................... Issued....................................................... Date J THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALTH ......................... own.......OF.........RarnstaUe....................................... 3 TwprtifirFa e XA THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired (X ) by..................•-••-•-......••---••..........-•-•-•----......_..--•--.....----•-......------......---••-......_._.........----•••------------•-•-----...-••--•.......•-•-...-•••-•---•••......_-- / Instiller . ? / has been installed in accordance with the provisions of TITL; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--- _Z-: _________________ dated------------.................................... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... No..991-...._....... � F�s....��,e'er.. .... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ..t Barnstable - AVVfirution for Uiipuual.. AD Tonstru rtion rrutit Application is hereby_ made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Harbnr Village Cnnd-miniums Units 39 4,51, 6 & 7 -.. .-- •-•-• --- ....:.............................................. ..........•-----•--------.........-•-•--------•--•••-•._...------...........................---... ................ - - �.... .. Location Address or Lot No. ._A� ,_?_.� �. .."1,_.Yaxm mthl.. 673 .....SL.:.11Yllld..sit..ill�ti l Ca15.................................................. ........ owner Address i a ...................... r............................................ ....__.......•••.._..._..••••--•--•••...........-••-••.._...••------•••--•-•--•-•---..........-•-- s Installer Address Q Type of Building _ Size Lot____15.8..acresSq• feet U Dwelling Y_No. of Bedrooms___.._l3_.................................Expansion Attic ( ) Garbage Grinder ( ) U . Otligi—Type'l'of Building 5..:b,1d9.-5 .......... No. of persons.......2Ei________________ Showers ( ) — Cafeteria ( ) a >' Other-fitures i -------------------------- - Q W Design low_______55..:` ': _:___:_.,� ___gallons per person p5>4 day. Total daily flow.1430 Ions. WSeptic Tank—Liquid capacity+ 8._.gallons Length____1__-___.._._ Widthk_____________ Diameter__-_____.______- Depth________.__.._-_ x Disposal Trench—No.___=________________ Width.....................Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.A_plts._,.. Diameter..... q.......... Depth below inlet....6g_-.......... Total leaching"are�196ga1� Z Other Distribution box ( X), Dosing tank ( ) Percolation Test Results Performed ...Inc.. Date__February 18s 1982 as Test Pit No. 1___.2.........minutes per inch Depth of Test Pit---- 3.__....__.. Depth to ground watetn^n__encnuntered Test Pit No. 2..........4....minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Q+' •••••-••----•-•--•------•---••••••-•-•..............•-•......__.._..•-•-••-•••••............._..•••.......................................................... D Description of Soil..........l^er1Y__t^P ^.=is1: A;Sanc y._subsni_1_,•_medium sand ------------•-•---•-----------------------••••••••.....----..••-•- A�I V .____________________________________................................................................................................................................................................... W _______________________________________________________________________________________________________________________________________________________________________________________________________ V Nature of Repairs or Alterations—Answer when applicable._.___!p rade existing system --------------------------------- --- ---------------------------------- •--------------------------------------- -----------------------------------------•------------------------------------------------•••••---------------- Agreement: . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTIT' :�e-of 5 of the State Sanitary Code—The undersigned further agrees not to place the system in .{ operation t�vl�lli �ifi Compliance has een issued by the board of health. 3114� +43 Date Application Approved By--•••• •-•-•-.. ------ ......................• ----•---.. .x te:P............ Application Disapproved for the following reasons-..................... -----------•----------------------------•-----------------------------------•••.....------ ................. Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i ........................T!Nn......-OF.........$arjM to 1e........._................-...................... CIrrtifiratr of Toutpliunrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired (X ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at- has been installed in accor nee with the prcvi ons of TII'L : 5 of The S a e nl ary Code as described in the application for Disposal Works Construction Permit No.&V_i f, ___________________I dated.--............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BI�CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tnwn...............®F. Barnstable N .� ...... FE 7................ Disposal Workii TUunutrttrtiort rrutit Permissionis hereby granted.........................................................................=----•---•---...-----------------------._.........__......_....------ to Construct (X ) or Repair (X ) an Individual Sewage Disposal System atNo ............ ---- ....................... Ste► y as shown on the application fo Disposal Works Constr ction Permit No __________________ Dated....... ___..____.___....____._._.... 0 C .. ----_...._ DATE................................................................................ 5 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r n Fmc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ..........................................OF_........................_...._......-.----.--..........._•-----------.................. Appliration for Dhipoii al Workii Tnnitxnrtiun Pamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Harbor Village Condominiums , Units 10; 11912 & 14 ................_..............-•---..... ........ .._........... •••---•---'••"•---'-'••......--•.............--•-•••'-•••••••••--..................-•--.......... Rnnaid S. Rudnick..oc...... Address 652 Main "St., W. Y°sdr&Wth, Ma. 02673 ......................_..........................•--••---------------."•••"......•-'-•-.•--•.. .........................-.................. ............................................... Owner Address W Installer Address Type of Builtg 6 Size Lot---15a8-..dGx0-S.'F1r.1M 0-4 U Dwelling—No. of Bedrooms------------------------- _-_--Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building 4 bldgs.--------- No. of persons ...............:.. Showers — Cafeteria a YP g ------=----- P - ( ) ( ) p' Other fixtures -----------------•------•----•-- . W Design Flow.....55..................................gallons per person per day. Total daily flow....660.................. .__.-_______gallons. .W Septic Tank—Liquid capacity-1g gallons Length----- 1.._.. Width.....6........ Diameter-`-__.... Depth6#...1��.._.. x Disposal Trench—No..................... Width...:................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...2__-Pit$---- Diameter.........14....... Depth below inlet-.A!............. Total leaching area..118894214* Z Other Distribution box ( X) Dosing tank ( ) `-' Percolation Test Results Performed by....Doyle.-Engineering-AsSaC.,...TnC•Date....FebTuarx__18)__1982 ,Wa Test Pit No. I...2..........minutes per inch Depth of Test Pit....... Depth to ground waternnne._encountered Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------............. �+ -------................ .----------------._.......----------------------....-...--------.-.-------•---------------- ._----- O Description of SoiL___________. a! Y.._t }2 �?ii,___sendy._-i�am:•_medium-sand,_.Adium and__course sand x U --------------- W UNature of Repairs or Alterations—Answer when-applicable______Upgrade-94 Sting__Syst9R............. '•--------•------------------------••--•---•--•----•-------•--------.......-..........................................-----------------------------------------------------------------..-..._.-----•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with >_ the provisions of T I T I S 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Co fiance ha een issued by the board of health. s e . = = ]�-................ ................... .. 4U�V Date Application Approved BY --_--'�- �ew....... Date Application Disapproved for the following reasons:-------•-----------------------------------------------------------------------•----------.....-•----........... ----••--•---•-----•---------------------------------•---•--------------'--'--'----•-•-------------------------•--------••-----•-------••------------------------------••--•••-----------••••-•---....... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS L (jf k BOARD OF HEALTH P iS ��.Wn.................OF....B.az.ngit.Ilblg...................................................... TrrtifirFatr of ToutpliFanr P All- THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired by...............................................................................................-----------'-"'••-•••..................................-••••---•---•---'-""......---"......-"-' . I Installers J atu e................ ---•----- ./ ,. Z4.V............................................. has been installed in accor�with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..49a_-_,F1............... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector..................................................................................... ooz "�� No.... .._....... FRs............._..... . THE COMMONWEALTH OF MASSACHUSETTS. BOARD OF HEALTH T^wn Barnstable ...--••. --- ..."....."...---.....OF................................................................ Application for Uh4p ti al Works Tun,strurtion omit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Harb-,r Village Cpnd-miniums Units 10, 11,12 c. 14 ...............-_................................................................................ •••••-••••--.....••••••...•••••••--••••••••••-•-••-----•••••••••••••••-••......................... R^nald S. RudniekLocation-Address 652 Main St., W. Y'lWbth, Ma. 02673 ......................__........................................................................ ..........-•...................................................................................... Owner Address W Installer Address Type of Build' g -` Size Lot....15.8 acresSq"feet Dwelling- No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ."�.bld�s._____.__ No. of persons......:�.................. Showers ( ) — Cafeteria ( ) 0.' Other fixtures --------------------------------------------------- --- W Design Flow....... 5................................gallons per person per day. Total daily flow.....660 ....___.. �9ps. WSeptic Tank—Liquid capacity..15 gallons Length......1�•_.._.. Width................ Diameter----.............. Depth$.......•..... x Disposal Trench—No. .................... Width. e............ Total Length.................... Total leaching area.....11 S-- sq. It. Seepage Pit No.__2._1 1tA... Diameter.................... Depth below inlet..............:.... Total leaching area..................Wif" Z Other Distribution box ( Dosing tank ( ) - - "" Percolation Test Results Performed by...__Dnyle EngInee AssoC., Inc.Date..._.February 18, 1982 ,aa Test Pit No. I....a.........minutes per inch Depth of Test ...... Depth to ground water nine enc..entered fZ4 Test Pit No. 2..:............minutes-per_inch Depth of Test Pit..........:.......... Depth to ground water........................... P4 -------------------------------------------------------•----------.------------- .......... D Description of Soil..............SanaX.. ^P��il_r_._s$ dy- Imam, medium sand, mud tam and curse saricl -----------------------------------•---•--------------------------......--------------- U ..............................................---•-------------------•---•-------••----.....�..-----•---...---------------------------------•--------------....--------._......--------.....----------- W x sting system Nature of'Repairs or Alterations—Answer when a lieable__.__._..pgrade exi -------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------ Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in o ation..until a Cert' cat oof/ACo fiance has been issued by the board of health. Date Application Approved By.. ---------------------- ----•- ......................................... Date Application Disapproved for the f oll n rlY 'i' :w• 4 ...................................................... ................................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tnbvn:..:..i.:,:..OF......Barnstable .................................................................. mWififiratr Of Toutplitanrr THIS IS TO CERTIFY, That the Zridividual Sewage Disposal System constructed ( X) or Repaired ( %� by-•••••••.......................................••....._......._......_ ....•••••-.....-------•••••......---••--•••-•••--------••------•---•-•-••--•••--•-•---..............--.............. Installer at.---•-------------------••----•---•-•••.................•---•--------------•-•--. •----•----------•---------------------------------------------------------•---•------•-----------------* b nstalled in accordance with the provisions of TITI;' 5 of The State Sanitary Code as described in the aPPj� reQjsP o st 'prmit N '/0i�- SI4e -------------------- THE ISSUANCE OF IS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT.THE SYSTEM WILL FUNCTION SATISFACTORY. c9v —f 1 DATE............................................................................... Inspector................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T-,-,4vn Barnstable + ..........................................OF.................................................................................... No......................... FEE................................. l" RaposFal Works (ECnnstrnrtion lermat ;* Permissionis hereby granted----------------------------------•----.....------•---••..........--•-••-•--------.•_...------------.......-- ....................... .... to Construct (X ) or Repair (X ) an Individual Sewage Disposal System at No j� Street as shown r a licatie f r osal Woks Co tructio Permit No.. __....`._ _. Dat f r_....... . '�� ,. i � ,��„�,., -- ,�� ,;;--/--,�� ,,�•j .......................................... ............................................................ s- .................................. ..:. ..... Health DATE.. .. ......-•-------------••----...r oar o FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 1'►1 nn . 1 ? I I 177, I ; alc - --- : `I �r LL ti � o T Cos �_:1 I t . 117 i 7b. �. -� N ,� (_ EIEt LTH. DEPT. - x TOWN0� ",!'P<' r1 _E ,gC�4'ES �i FEB 1 p 1982 / 1 4 0 C ` " •-•-��S.ti.. e!�_ I , 'A j A. 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