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0178 MITCHELL'S WAY - Health
178 Mitchell's Way Hyannis. ..P A = 290 141 0 ul a � n d .f LOOO TOWN OF OF BARNSTABLE LOCATION i (�h,o L�Se4dSEWAGE# VILLAGE i ( �ASSESSOR'S MAP&PARCEL ty ,,INSTALLER'S 1,fAME&PHONE NO. SZ)P-S1/9 "tI76 0 SEPTIC TANK CAPACITY ©0 Q LEACHING FACILITY:(typess) a ., !lJ U (size) /3 iU •/02 J NO.OF BEDROOMS o� OWNER 1beNOV i'S PERMIT DATE: COMPLIANCE DATE: U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility.) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of a chiQn�facility). feet FURNISHED BY w L>j cu w s `�o ry� G � � a �1 Town of Barnstable P# Department of Regulatory Services pFIKE?i Public Health Division Date ,Py o 200 Main Street,Hyannis MA 02601 ( i rr7 / BABNSMIM MA9 /�`17y . \/ 9 9. � . ibJ959. �e B�'0� °reo Date Scheduled A taw Time Fee Pd. %00 Soil Suitability Assessment for Sewage Disposal. Performed By:�1� Yl l tt, Witnessed By: +•-b�NI6- arcunaL ........_....�...:::v::::::................_..........r....._..........::........................v..r...........r ..r.::..::,........�....r......::!..l.r..i..r._....v.r:,...:...........:.....::..:1..........r.....I...I..I....:.r.:..l:.....:..r....:....r�.....::2:::::r:r!v.::i!;i.:.:.;._...r.,..r....vr:r.......:...r:.ili:.�R..,.r!.!.i.!::r�!..:.r.r:.r.i1l.!�Y:.;..!.4.rv......r.._:.:.�..:::._.r.r.:.::.r:.:.:.......1ri.1.........r:.....r..._...r.. .. :..:...::.:..:._.:..:..:..Location Address y Q� 'rL-t} 1S�J/0 Owner's Namey 1.� j.... ....,. 1 /(7J ��/tr{� Address �t 4��� 1G �c0 vpjZ. ` � � �sj, Gaas. `t'J Assessor's Map/Parcel: w�.p '2. 0) A % �� Engineer's NameLIL NEW CONSTRUCTION REPAIR Y Telephone# -Q8-5"10®3�33 Land Use 3S Slopes(%) C)' Surface Stones Distances from: Open Water Body 1.9 ft Possible Wet Area ft Drinking Water Well 0 cV- Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to.holes) 2 [Z7. 32` Parent material(geologic) Q.K C&2L4 kso"S-A-AAZ Depth to Bedrock .ai Depth to Groundwater:. Standing Water in H. Weeping from Pit Facei Estimated Seasonal High Groundwater ev::r..:a...::::..:..�!.:.:..:..r....r.._,..,:::..�::...:::::r.:.........................:...... .:...... _ _.._-_........................_.:.:I:....:v::_...._...r......!.r...r...i:.r!.u....,._........m_..._...I....:..r............!!........:..r...:r.:r...._....:.:::rr.rn.........l.:.n:.:::.....,.:.... OJAI !....._...._..............:....>...r...... .....r... ... .. .._ ... ..::............ .:.. ..:... .:_. ..r..:r :. �. .. ._:�:..,.,...:.............:..::.::.r.. Method Used: Depth Observed.standing in obs.hole: in. Depth to soil mottles: A in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwat r Level N :.i..........................rr.....:.:::....r.r..v:.,r...._r:r:.:,a....:.r:..:..I....:..:..I.r:.:._..........i_i'::::r:::�:,;..:_:::::I.:::::��::::........_...r............._..,......._........... .. rer......:.. Observations z Hole 4111r 1 Time at 9" St t Depth ofPerc �tl Time at 6" Start Pre-soak Time @ \ l Time(9"-6") End Pre-soak TO-0 Rate Min./Inch �tvt Site Suitability Assessment:'Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----=----- Q:HF.ALTWWP/PERCFORM � �Arir'�t�rJ s�'4 e►J c� Ur�fA'�-"�'�'� Nii.�s, t :.::.. ..... ...... .. .... ..............BS........ ATI. L ..:........:;:::.::.;::.;:;............... .:: . ........:..::.:::.:. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. ° Gravel) Ii 0 .4tj o l� 2- toe C! -c, , / io 43 A tz- Lt'v :. ............. >: < .::.<..::...: ...:..:::Q........E{..:..V:..:......:...:...:::Ht7�:L...::LG.:...::. ...:...........H.olo.#.............:.:.::.::.:::::.:::::::::..::::::::.. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consustefic Gravel 00M :.:::::::_.:.:..;;.:;::;:.::::;:::::::::::::::::::::.:::::::::::::::::::::..:.:.......................::.;:.::::: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistengy. Gravel) - DEEP::Q�..... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes ✓ Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the.soil absorption system? If not,what is the depth of naturally occurring pervious material?— Certification I certify that on 4IfA (date)I have passed the soil evaluator examination approved by the Department of En ronmental Protection and that the above analysis was performed by me consistent with the required training,expe 'se and'experience described in 310 CMR 15.017. Signature Date O-4,�J �8 �'p THE raw Town of Barnstable Barnstable ti ~\ AS-AmMca city 1 Regulatory. Services Department I ,tSAILVSTAULE,I+� � : ON Public Health Division a OArF M:�A — 200 Main Street 601 MA Hyannis 2 2007 y 0 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO February 22, 2008 US Bank National Assoc. 425 Walnut Street' Cincinnati, OH 45202 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 178 Mitchell's Way, Hyannis MA was last inspected on February 4, 2008, by Mark Nard one, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • 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 s due to an overloaded or.clogged SAS or cesspool You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in fature enforcement action. PER ORDE THE OARD OF HEALTH Thomas McKean,R.S., CHO Agent of the Board of Health �m+t- ��ote a�Sa oao� t 63g (Aq is Q:\SEPTIC\Letters Septic Inspection Failures\178 Mitchell's Way.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i Pro{3erti7 Address � 1 �1 U0 �`��°I Owner Owners Name information is required for sMA every page. CityRowtt ta3 to rip- CZ ode ITat6 dffiftffection Inspection results�must be submitted on this form. Inspection formo may not be altered In any way. Important: A General Information When tilling out � n forms on the computer,use 1. Inspector (Aa . .,. only the tab key tumove r-don 4nn,JL' �'�c1�,. 11c�o �ct� yS2b"z. cursor-do not use the return Name of Inspector - key. Company Name Midge Home & Septic Company Address 27 Tiffany Circle c — State Zip Code Sob �M Telephone Number License Num or ��� 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.l 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 <I > Inspbdoes SigrfaWure Date The system inspector shall submit a copy of this inspection report to the Appro ing 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 DER The original should be sent to the system owner and coP ies•sent to the buyer, if applicable, and the approving authority, ""This report only describes conditions at the time of inspection and under the conditions at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. !smsp.doc-A06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments lite IN :i( t r le o�. �. P op i Ad ress ' Owner Obi ne s e information is required for 1►m.1�I c _ every page. cityfrdwState ' Zlp a Date of 16406851ion B. Certification (cont.);. Inspection Summary: Check A,B,C,D or E/always complete lete all of Section D A) System Passes: ❑ I have not found any\in1 on which indicates that any of the failure criteria described in 310 CMR 15.303 CMR 15.304 exist. Any failure criteria not evaluated are' indicated below. Comments: B)° System Conditionally Passes: ❑ One or more system co ponents as described in the"Conditional Pass"section need to be replaced or repaired.The ystem, upon completion of the replacement or repair, as approved by the Board of Health,will p Answer yes, no or not determ'in (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and o er 20 years old'or the septic.tank(whether metal or not)is structurally unsound, exhibits s bstantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if th existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass insp tion if it is structurally sound, not leaking and if a Certificate of Compliance indicatingr that the to k is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out r high static water level in the distribution,box due to broken or obstructed pipe(s) or due to a br en, settled or uneven distribution box. System will pass inspection if(with approval of Board of H alth): ❑ broken pipe(s)are replaced \, ❑ obstruction is removed t5irsp doe•rgfOg ritle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts, t i Title 5 Official Inspection Form = Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 17.1P M trf wat C rJA . Property Address IF I,15 ter n y u a Owner Owners N s information is required for l�y�r7Y every page. City/Tow tS ateM Clyer Oafs-lbf I apection B. Certification (cont.) B) System ondltlonally Passes(cont.): ❑ di tribution box is leveled or replaced ND Explain: • ❑ The system requir pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass ins ion if(with approval of the Board of Health): broken pipe(s) re replaced obstruction is re oved ND Explain: C) Further Evaluatlon Is Required y the.Board of Health: F ❑ Conditions exist which require fu r evaluation by the Board of Health in order to determine if the system is failing to protect publ' health, safety or the environment I. System will pass unless Board f Health determines In accordance with 310 CMR 15.303(1)(b)that the system Is not nctioning In a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 fe t of a surface water Cesspool or privy is within 50 feet f a bordering vegetated wetland or a salt marsh 2. System will fall unless the Board of H ith(and Public Water Supplier,if any) �'. determines that the system Is functioning n a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil a sorption 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. t5msp.doc-08i08 Title 5 Official Ins pection form:Subsurface Sewage Disposal System•Pays 3 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M f—nCfjWf UA V Property Address . owner � " � Owner's Name information is required for every page. City/To n State Zip Cods Ddte bf Inspection B. Certification (cunt.) C) Further Ev uation le'Required by the Board of Health (cunt.): ❑ The syste has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from rivate water supply well'". Method used to etermine distance: "This system passes if a well water analysis, performed at a DEP certified laboratory,for coliform - bacteria indicates absent the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t t 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 Al Systems: You must Indicate"Yes",or"No"to each of the following for pjl inspections: Yes No 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 ❑ 1?1 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 ❑ d 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. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water.supply. tEmsp.doc-0" Title 5 official Inspection Form,Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments Property Addro Ys$ i OwnerN Owner's Name information is g' required for �.�! Q Z (A every page. CltylTo 'State Zip Code Dath df Inspection B.•Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ �' 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. 13 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!stemis a cesspool (� Y pool serving a facility with a design flow of2000gpd- 10,000gpd. E] The system falj . I have determined that one or more of the above failure k 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.; 4 For large systems, you must indicate either"yes"or"no"to each of the following, in additionto the questions in Section D. Yes No d 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 z- _ 0/ 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. t5ivsp,doc•ij&06 idle 5 Official In , spection Form Subsurface Sewage Disposal System-Pape 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments al7� M tTt u i'Y r f L�4 t/ Property Address r �!} Owner o � 1�,/I ink &1 14 ers N ms information is required for ' Arld!S ®160/ Mot every page. Cdy/T wn .state" Zip Code Date of Inspection ` n.4 C. Checklist Check if the following have been done. You must indicate"yes"or"nos as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board f Pa o Health ❑ 2f 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 rec this inspection? ently or as part of ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) El Was the facility or dwelling inspected for signs of sewage back up? 0 Was the site inspected for signs of break out? ❑ 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? 0 Was the facility owner(and occupants if different from owner)provided with ` information on the proper maintenance of subsurface sewage disposal systems? f 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. N : d ❑ 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)] I - l5insp.aoc•G8106 Tale 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 15 N; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal y _ 9 po#al S stem Form-Not for Voluntary Assessments Pr erty Address w bar)kl-- NO Owner Ownet's Name , Information is f Ill S , required for �� � t1.160� every page. City own State Z' Code IP Date of Inspection D. S. stem Information .Y , Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 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? f ❑ Yes No Seasonaluse? Yes No -Water meter readings,'if available(last 2 years usage(gpd)): Sump pump? Yes ❑ No Last date of occupancy: _ Date CommerciaUlndustrlal Flow Conditions: Type of Establishment: Design flow,(based on 310 R 15.203): Gallons per day(gpd) 'Basis of design flow(seats/perso sq.ft., etc.): Grease trap present? - � " ❑ .Yes No , Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys m? Yes ❑ No Water meter readings, if available: _ Last date of occupancy/use: ~° Date Other(describe): ;5wsp.aoc•c" Title 5 Dff c&i Inspection Form:Subsurface sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments Property Address ur)�Owner IUD Owners Name information is , required for WVANO lS Q 60/ every page. Cityfrown '1 V� State Zip Code Date 6f Inspection M System Information (cont.) 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 rP Y m ❑ Single cesspool Cl Overflow cesspool , Privy Cl 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. El Other(describe): Approximate age of all components,date installed(if known) and source of information: M -------- -�--YES=----=------------ Were sewage odors detected when arriving at the site? ❑ Yes No c5,nsp.doc°.;8r06 Titte 5 Official Inspection Forth Subsurface Sewage D sposal System•Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments n rr<,t4(( 04 Property Address an!` ! ` y Owner Owner's Name IV F information is {� 13 required for 5►�` h O160/ every page. Cdyi I own State O Zip Code Date of Inspection D. System Information (cont.) 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: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 600-o <t7,Jornod Septic Tank(locate on site plan): A Depth below grade: feet Material of construction: 14concrete ❑.metal ❑fiberglass ❑ polyethylene ❑`other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes - - - --- ---- -- - -- - - - ------ - ------- - --------------------------- ------------------------- ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness a +. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Now were dimensions determined? t51nsp.00c•u8/06 Title 5 Officiet Inspection Farm;Subsurface Sewage Disposal System•Page 9 of 15 - Commonwealth of Massachusetts - Title 5 Official Inspection Form �~ Subsurface Sewage Disposal System F� Not for Voluntar y Assessments 471 MITc.IVU PV Property Address ,,� nn Owner Owner's Name information is r C required for J every page. Cityfro _ St to tp Date of Inspection D. System Information (coot.) Comments (on pumping'recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels.as related to outlet invert, evidence of leakage, etc.): or All �uraVj .' �/�BPS 140 ; Y/i Grease Tr (locate on site plan): Depth below de: TUN Material of cons tion: [],concrete metal ❑fiber lass 9 ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top outlet tee or baffle Distance from bottom of scum to bo in of outlet tee or baffle Date.of last pumping: Date Comments(on pumping recommendation inlet and outlet tee or baffle condition, structural i liquid levels as related to outlet invert, evide ce of leakage, etc.): ntegrity, Tight or Holding Tank(tank m st be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal fiberglass `� 9 ❑polyethylene ❑ other(explain): t5insp.doc•�306 Title 5 Dfficial Inspection Form;Subsurface Sewage Disposal system•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System = P y Form Not for Voluntary Assessments 7/ MrTcHEcc Prf arty A dress Owner Owners Name information is required for H A41N eve Ci every tY!r a State Zip Code Date of inspection D. System information (cont.) 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: Type: LJ _ 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 po vegetation, etc.): nding, damp soil, condition of i 4FAOY SI006F (,j&&y00EA, 505 or '5"nwJoc•pyigg Title 5 Official Inspection forth Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments 11 N rig H&cs W&►�� Property Address Owner .(.h information is Owners Name required for M/A ►�. /4+ 0.115l every page. Cityrrow ,1 l State Zip Code. Date Inspection ct o n D. System Information (cunt. Tight or olding Tank(cunt.), Dimensions: Capacity: gallons ------------ Design Flow gallons per day Alarm present: ❑ Yes ❑ No Alarm level: k Alarm in working order. ❑ Yes ❑ No Date of last pumping: 1, j {Date Comments(condition of alarm a float switches, etc.): Attach copy of current pumping tract( ired). Is copy attached? Yes ❑ No Distribution Box(if present must be ened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box'is level and,distnbuti to outlets equal, any evidence of solids carryover, an evidence of leakage into or out of box, etc.): y Pump Chamber(locate on sit Ian): Pumps in working order: Yes :4 ❑ No Alarms in working order: El Yes ❑ No t°innp.aoc•J M6 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 15 Commonwealth of Massachusetts Title 5 Official . Inspection Fora Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments nr N('f"oycf (.4y Property Address , Owner OwrWftNa information is required for NV NAIIS 0601 every page. City/Town State Zip Code Date of Inspection . D. System Information (cone). r Cesspools.(ce spool must be pumped as part of inspection) (locate on site plan): Number and con uration- Depth—top of liquid inlet invert Depth'of solids layer „ Depth of,scum layer Dimensions of cesspool Materials of construction . Indication f o groundwater inflow" , ❑ Yes ❑ No Comments(note condition of soil, si s of hydraulic failure, level of ponding, condition of etc.): vegetation, Privy(locate on site plan): ' Materials of construction: Dimensions " Depth of solids Comments (note condition of soil; signs'of draulic failure, level of ponding, condition of vegetation, etc.): x, t5rsp.doc.,)alO6 T,IW 5 Official Inspection Form:Subsurface Sewage Disposal System-Pap 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17� M fko(.U . PropertyV`� Owner Owner's Name information is HV4AJ?,)15 Q;60/ required for 7 _ every page. Cltyll'own State Zip Code Date of Inspection D. System Information (cont.) 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 3 1 64 ono t �� a 43 3y �3 3y' R t5irsp doc•48106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 .f Commonwealth of Massachusetts Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - I7�" N�CN�cSS ta4y , Property duress Owner Owners Name information is J"1011)15 (� ai'©l required for --L ( a/ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar El Shallow wells Estimated depth to ground water. 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:. of 0tg111AYT-0#, f-(FU�ioos t5"csp.doc•08/06 • Lth 5 Official Inspection Form:Subsurface Sewape Disposal System•.Pegs 15 of 15 q q No. 2 O� .. Z t 1 i Fee 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS YeS Application-for 3k9pont *pgtem Cun trUction Permit Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. 1-7$ M IZ Chi.[L L Owner's Name,Address,and Tel.No. Dg 1 i4is 1<94LK.ADO Assessor's Map/Parcel 2 LA I Sa8 S 7 7 — SZ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Os)2�O1S'^ -SACK L..Ah,u0c1LS S-416-77331 0 Type of Building: Dwelling No.of Bedrooms 2, Lot Size sq. ft. Garbage Grinder ( ) A/0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2. 2. gpd Design flow provided `� 3 gpd Plan Date 7-- 14/ — ZOO& Number of sheets Z, Revision Date Title s 1'f CL 'P y Size of,Septic Tank k 0 d d Gr ALL QiJ Type of S.A.S. Description of Soil Nature of 7,ir,or Alterations(Answer when applicable) /V c KJ6 0 Z Soo 40GG/,� w b l6 ,S?OwL /LL %N Af Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo dZalth. 4 Ae Signed w► Date z �� Application Approved by Date 7_77 * O Application Disapproved by: Date for the following reasons Permit No. Z!3 O � 2-. Date Issued L $ . No., 0 l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes, ZIPPgicatiott for �Digogal *pgtem con truction permit Application for a Permit to Construct( Repair(0' Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot No. 1 Fj M IZ C-H C(r L. �S t vA Owner's Name,Address,and Tel.No. [�C wu 1S Assessor's Map/Parcel— Q..•• , L` t 7 -� � -7 7 c"z J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S IN A � � � � -SACK. (_T USA .5-4/,5--7 1 3 S �. Type of Building: Dwelling No. of Bedrooms Lot Size /0 .��(y sq. ft. Garbage Grinder ( ) A,10 Other Type_of:Building No. of Persons Other Fixtures Showers( ) Cafeteria( ) r Design Flow(min.required) a 2 0 gpd Design flow provided A gpd Plan Date 7— /q -- z o o Number of sheets 2r Revision Date Title Size of,Septic Tank k O O U 6 a, 0^/ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) N—4, A0 go)< �Z. � S;U Q f�q�4 (�.. c, F S 7o eG. -- i f C Z /�/ A O v 4 rA 14. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Ai ealth.� `Signed t� ( Dat".JtQL.,�I /G Ae 1. Application Approved by c'. Date 1O o Application Disapproved by: Date for the following reasons Permit No. '0 O's— Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of itompliauce THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( (/)Upgraded ( ) Abandoned( )by C N t-1 1 S LX g- 12 L4 A D O 1 -7 v M 1 T C_ N L LS at has been constructed in accordance �f with the provisions of Titles 5 and the for Disposal ystem Construction Permit No. 7►OUF'" Z�� dated -7 l Z00 ; Installer w W") �- i`�A�-J�`� �+ �, Designer =aC.le• LC, 5 CA�,LF, #bedrooms Approved design ow gpd C The issuance of this permit shall notobe construed as a guarantee that the system will functio IFa signe Date /` �240 Inspector _ No. Cao '{ Fee /U o — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migogal *pgtem (foowAruction J)ermit Permission is hereby granted to Construct ( ) Repair ( w ) I Upgrade ( ) Abandon ( ) System located at ` 7 6 vAA I T Gu Z L.L. S L^.,,,A f H A I H i S I ' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction�+mu t be completed within three years of the date of this pe� L,.�'./,/.Date �� Qgi Approved by G !�X Jul 22 08 � , uley 508-540-3344 p.2 + Town of Barnstable 'v 0. Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Of ::c;: 508 8£2-46�4 Fax: 508-790-63041 Dab— Sewage Permit# Assessor's Map/Parcel 1® 1 -'1 Installer & )lDesiQner Certification Form �be�i niei d �. -C Installer: kddress° _ + C� . � �r� Address:On -- - U)s LU Am was issued a permit to install a (date) (installer) at +a based on a design drawn.by t' address) datediaKva (designer) _ s certify that the septic system referenced above was installed substantially according to r1?e �e5ign, which may include minor approved changes such as lateral relocation,of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were-found satisfactory. 1. certify that the septic system referenced above was installed with major changes (i.e. reater than 10 lateral relocation of the SAS or any vertical relocation of any co msponent ` �of the septic system) but in accordance with State & Local Regulations. Plan revision or €, mortified as-built by designer to follow. Stripout (if required) was inspected and the soils Wcf6 found satisfactory. (Installer's Signature) r LnNt)ER -CAULFY,=CIVIL c .o � r A• 4,l e+� RN ture (Af i. " `' Stamp Here)Pl..,KAS� ® BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF C MPLIA CE SILL NOT BE ISSUED UNTIL BOTH TlHIS FORM :AND AS- lJIL`.;r CARD ARE IIECIEIVED BY THE 13ARNSTABLE PUBLIC HEALTH DIVISION. T i a Ise YOU. gai�iiice rcerrns\<_esignerczrtification fo�i.doc • TOWN OF BARNSTABLE' LOCATION A SEWAGE # 0 N VILLX63 I I JA✓1/1 13 t ASSESSOR'S MAP &'LOT<�'tO N INSTALLER'S NAME&PHONE NO. G01?0^ �UrN OV.S SEPTIC TANK CAPACITY I!/Ua �\ pnJ LEACHING FACILITY: (type) �� �X�°, (size) NO. OF BEDROOMS BUILDER OR OWNER I�/ /i err PERMIT DATE:� COMP IANCE DATE: 3 O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply,Well and Leaching Facility (If any wells exist - on site or within 200 feet of leaching facility) Feet _ Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Y ,y �A p A , � u A - 0.0 Aa- aY A3- 3 S 133i 3S 3 TOWN OF,-BARNSTABLE L?CAT10N O /h 2.�!S WAV SEWAGE # VILLAGE Ny/�,t/1�S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I UUD LEACHING FACILITY: (type) P, x(9 (size) S 7 0^4- NO. OF BEDROOMS- BUILDER OR OWNER �� ��^ Derr PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 'I - a3 iq3" 3� 3 I No. pPty Fee i AI THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpphratton for 33i.5po0ar *pztem Conotruction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. °(�`)I G k-li 4N`/ Owner's,Name,Address and Tel.No. Assessor's Map/Parcel L; .1�,�, V,1, :i'1 'M I G h 11.91 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J rl'i= a,8 S H Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature�of�Repo' or Al tiogs..(Answer when pplicable G 1 �/" /c- 1� 14E A C,k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by/tyis Bo9rd of Health. Signed Date slugloA Application Approved by Date a Application Disapproved for the folio ing reasons Permit No. ! O 2.2-- Date Issued THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ✓ V ' PUBLIC HEAL-TH,:DIVISION - TOWN OF BARNSTABLE,. MASSACHUSETTS Z[ppricat_Wfor Mitpogar *pgtem Couttruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. `1, m) G ! V.1)i� Owner's Name,Address and Tel.No. + N, �V,*.y Assessor's Map/Pazcel '�� LI', I,O � V•) l Installer's Name,Address,and Tel:'No. ���� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A�S. Description of Soil Nature f R r l i n Answ r when li 1S' atu e o epa o A t o �3( e pp cab e) GE P_j �i s � K 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code.and not to place'the system in operation until a Certifi- cate of Compliance has-beendssued by s Board of Health. Signed Date�� Application Approved by Date .s a' Application Disapproved for the folio ng reasons Permit Noy�'7- 1;24j� Date Issued 2 G.� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance •� ,. THIS IS TO CER , th the On-sit wage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( )by U U at rM M ` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2Gid?-,2.t r�dated 9 6 Installer Designer The issuance of this p t shall not be construed as a guarantee that the systems ill function as designed. , Date Inspector �,,.v, n, No. (JO oZ— ���. Fee J y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS xig;poal *p$tem Con0truction Permit Permission is hereby granted to ConstructRepair( )Upgrade( )Abandon System located at / 1 S iU N and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to E comply with Title 5 and the following local provisions or special conditions. Provided:Consttrructio must be completed within three years of the date of this p it. Date: / 0 Approved by /�l. a TOWN OF BARNSTABLE LOCATION ` E- Mi Gll A SEWAGE # o a'od0 VILLAGE 1�ti8rtrl13 ASSESSOR'S MAP & LOT(;90 l" INSTALLER'S NAME&PHONE NO. Or` 2w," vS SEPTIC TANK CAPACITY /C'&b �\ S jL l t —4n LEACHING FACILITY: (type) t"� GX�O- (size) 10" GAL NO. OF BEDROOMS c� I BUILDER OR OWNER I� /i Perr\4 PERMTT DATE: U COMP IANCE DATE: �31 az Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply.Well and Leaching Facility. (If any wells exist on site or within 200 feet of leaching facility) Feet _ Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by S 'SV �_-e --CIO bf --ea -e Cie - a to f _ , 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 FORNi PART A RECEIVED CERTIFICATION Property Address: 178 Mitchells Way JUN 0 4 2002 Hyannis, M4 02601 TOWN OF BARNSTABLE Owner's Name: Lillian Perry HEALTH DEPT. Owner'i Address: Same Date of Inspection: May 28, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: . James M. Ford Map: 290 Mailing Address: P.O. Box 49 Parcel: 141 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 Section 15.340 of Title 5(310 CMR 15.000)., The system: ✓ Passes Conditionally Passes k Need -Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 3:2002 The system inspector shall subm 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 1 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 178 Mitchells Way Hyannis, M4 Owner: Lillian Perry Date of Inspection: May 28, 2002 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if 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 pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping 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 removed ND explain: 2 • Page 3 of l l . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 178 Mitchells Way Hyannis, AM Owner: Lillian Perry Date of Inspection: May 28, 2002 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 CNIR 15.303(1)(b)that the system'is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 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 i • Page 4 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION '(continued) Property Address: 178 Mitchells Way Hyannis, AM Owner: Lillian Perry Date of Inspection: May 28, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"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.] No (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well ` If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner shouldcontact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 178 Mitchells Way Hyannis,AM Owner: Lillian Perry Date of Inspection: May 28, 2002 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 ? n/a 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: 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 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address: 178 Mitchells Way Hyannis, MA Owner: Lillian Perry Date of Inspection: May 28, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No (if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use(yes or.no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -21,750 gals.; 2000-27,000 gals. Sump Pump(yes or no): No Last date of occupancy: • Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: - Last date of occupancy/use: OTHER(describe): 1 GENERAL INFORMATION Pumping Records Source of information: Pumped in April 2002-per owner Was system pumped as part of the inspection (yes or no): 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) Inn ovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) M Tight Tank Attach a copy'of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM- NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 178 Mitchells Way Hyannis, MA Owner: `Lillian Perry Date of Inspection: May 28, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 32" Materials of construction:' " cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20 Material of construction: ✓ concrete ' metal __polyethylene_fiber lass g _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: 1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom ofoutlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees were present. The liquid level was above the outlet pipe because the pipe was collapsed and bowed. A new outlet pipe was installed(Permit#2002-223). GREASE TRAP: None (locate on site plan). Depth below grade: Material,of construction: concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 1 I a OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 178 Mitchells Way Hyannis, MA Owner: Lillian Perry Date of Inspection: May 28, 2002 TIGHT or HOLDING TANK: None (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/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.): DISTRIBUTION BOX: None (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 CHAMBER: None (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.): 8 o Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 178 Mitchells Way Hyannis, M4 Owner: Lillian Perry Date of Inspection: May 28, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation.not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'with approx. ]'stone(hand probed) 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.): The pit had 4'6"of water on the bottom. The scum line was at the same level. There were no signs of failure. The bottom to grade was approximately 9' CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 { 0 Page 10 of 11 OFFICIAL INSPECTION FORM°- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 178 Mitchells Way Hyannis, MA Owner: Lillian Perry Date of inspection: May 28;,2002 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 . a _ ac' � a3 F13 3 S 3 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: 178 Mitchells Way Hyannis, M4 Owner: Lillian Perry Date of Inspection: May 28,-2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20'+/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 20'+/-to ground water at this site. ,a This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 . tol TOWN OF B RNSTABLE ®LOCATION // o o l rr—A e /�S Ud SEWAGE# 0T VILLAGE t n fir/, ASSESSOR'S MAP&PARCEL INSTALLERS AME&PHONE NO. �+ C ��i.� Io �g3 < SEPTIC TANK CAPACITY �0 LEACHING FACILITY:(type) 61G1 (size) NO. OF BEDROOMS 0 .OWNER Ko du PERMIT DATE: 7 /6 b v COMPLIANCE DATE: Separation Distance Between the: J l Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /d feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist �) within 300 feet of leaching facility). /"'� feet FURNISHED BY rr a \ o ° w � � C LOT 81 � LOCUS as , rn y H s WA o� LOT 80 ?' _ a E a6'a s. N ?5'42 4 SPOT GRADE o (typical) HE 100.3 0 DTP 1 - - + 100.8 25' �'SEgVE o LOT 79 0 ; AgEA 11 8 LOT- 73 O w -- LOCUS - MAP 23 0 jst o 1• X �..X CATION r •F • ISTING LOCATION ,. 0 OF LEACHING PIT - . � . TO _ EXISTING LO CATION . BE RE MOVED VED .,.DISPOSED OF OF SEPTIC TANK �_t ,. ACCORDING TO-, LOT -75 AS BUILT CARD i N SST �1G N o E$EDP JS�. He FLOOg 28 B J S'� 1p3. 3, LE cNr 1 �\ E OF J9�V 1006 , .QHN �G 7. 4 d b E ULEY4. r" 4. 100.4 \ 1C.516 .S.F. g74.04 99.5 SITE PLAN ' - PREPARED FOR L,62.84 _ _NT DENNIS KERKADO 0" _ \ A S OF 75° r 6� \ _ �SDGE OF P 178 MITCHELL'S WAY 99.4 J A� BARNSTABLE ALL J.E. LANDERS-CAULEY, P. E. I(I CIVIL ENVIRONMENTAL ENGINEERING 1V1 P.O. BOX 364 WEST FALMOUTH, MA 02574 0 10' 20' 30' 40' 8 540 - 7733 ph. 8 540 - 3344 fax M ASS.#290-141 DATE: 07114108 SCALE: 1" = 20' SCALE: 1" = 20 IDRAWN BY: JDR JOB N0. 1781 1 SHEET: 1 OF 2 fl 4 c .J 4 � ' MAGNETIC TAPE TO 139 INSTALL OBSERVATION PORTS ACCORDING TO TITLE 5 STANDARDS F.F. ELEV.=103_28 INSTALLED ON ALL COVERS 20'MIN. ELEV.= 100_7 4" CAST IRON OR CONCRETE COVERS ELEV'=LW SCHEDULE 40 P.V.C. / �l 4" ,CAST IRON OR SCHEDULE 40 P.V.C. DIST.=6.s_— _ --- INVERT DIS = CONCRETE COVER DIS = 12"MIN. /8LA11/2 OF SLP.=0.02 SLP.=O.005 ELEV.= 99.28 99 15 FLOW LINE T. 14.4_ SLP.=0.O1 i T -_ WASHED STONE _ INVERT o0000000000000000000000 0 0"0"0"0 0 0" — — ELEV.= __ o 0 0 0 0 0 0 0 0 0 0 o c ELEV.=9$.55 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0_o_o_o_o_o_o_o_o_o_o_o _o o_ o_ o o_ o o_o_o_< ELEV.= 98_90 ELEV.__-_- ELEV.= 8.58 ®®®® O ®®®® b gs 8- 0 8- b < 24" LAYER OF THE LENGTH of 98 75 i g o 0 0 0 0 0 0 0 OUTLET TEE IS a _-- O O O O O o ®®®lam®®®®®®® O O O O O O O /4" TO 1-1/2" DLIQUD�EP1B}i OFF - 4" CAST IRON OR OpOpOpOpOpOpO ®®®®®®®®®®® OpOpOpOpOpOpOpC`WASHED STONE ID THE TANK USED. SCHEDULE-40 P.v.c. DISTRIBUTION BOX o o o 0 0 o ER®®®®®®®®®® 0-0-o 0 o„o„o, ELEV. (SEE CHART AT RIGHT) LENGTH of IF MORE 'THAN 4' OF COVER. LIQUID OUTLET TEE USE H-20 LOADING USE STONE TO t EXISTING 1 000 GALLON SEPTIC TANK DEPTH BELOW FLOW LINE T0. BE WET TESTED IF LEVEL THE BED 4 FEET.......14 INCHES 2 ® ,4' 10" x 8' LEACHING CHAMBERS 6 9' s FEET.......19 INCHES MORE THAN` ONE OUTLET. AS NEEDED. • SET` EQUALLY SPACED IN A SEE slo CMR TO i BE PLACED ON - 3 ' , ` „ - - - - - - - - - - - 1 0 x 25.0 BED 15.227 (s) 6 OF STONE. OR _ MECHANICALLY COMPACTED SOIL. BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV =89_6 — SOIL TEST DONE BY: J:E. LANDERS-CAULEY P.E. WITNESSED BY: DONNA_MIORANDI—_--__— ----- PERCOLATION RATE: —.5---MIN/INCH P# 12292 _. P TEST HOLE, 1 DATE: 07-�14 0/_ 8 ELEV. PROFILE ILLi' Fi' I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPTH HORIZON TEXTURE COLOR MOTT. OTHER DEPARTMENT OF ENVIRONMENTAL PROTECTION PURSUANT SEWAGE DISPOSAL SYSTEM TO 310 CMR 15.017 TO CONDUCT SOIL EVALUATIONS AND THAT THE ANALYSIS GIVEN HAS BEEN PERFORMED NOT TO SCALE -8 FILL _ _ BY ME CONSISTENT WITH THE REQUIRED TRAINING, " EXPERTISE, AND EXPERIENCE DESCRIBED IN 310 CMR 15.017. I FURTHER CERTIFY THAT THE RESULTS OF 8"-16" D/A LOAMY SAND MY SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ARE ACCURATE AND IN GENERAL NOTES: ACCORDANCE T 310 CMR 15.000 THROUGH 15.017. 16»-32" B LOAM OF 1. THIS PLAN IS R o�FOR THE REPAIR OF AN EXISTING SEWAGE DISPOSAL SYSTEM. oHN -� 2. PLAN REFERENCE LC 27099B LOT 74 BARNSTABLE REG. OF DEEDS. 32"-108" 'Cl M-C SAND 10YR 5/8 PERC AT �a Y 3. THIS PLAN IS FOR THE INSTALLATION /REPAIR OF SEPTIC SYSTEM 48" i" . AND NOT TO BE USED FOR SURVEYING AND ZONING PURPOSES. o.35iQ? 0' `��- D <'SGN DATA: 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. NO H2O ox�n J7r �� TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS 108„-132„ C2 - MED SAND lOYR 6/4. s ' FOR THE SUBSURFACE DISPOSAL OF SEWAGE. ENC D 5. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN TEST HOLE 2 DATE: 07114L08 ELEV._100_8___ NUMBERQ '��IITI�OOMS 12" OF THE FINISHED GRADE. DEPTH HORIZON GARBAGE DISPOSAL —NDI E_(9�_____ .,TEXTURE . COLOR MOTT. OTHER , 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME, UNLESS NOTED BY FINAL CONTOURS:` » ,. TOTAL ESTIMATED FLOW 220_____ GPD 0 —8 FILL ( 11(L__ GAL./BR./DAY X -2—___ BR.- ) 7. ALL COMPONENTS OF THE, SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR SEPTIC TANK CAPACITY i�oOD c:Ai�_ WITHIN. 10' OF DRIVES OR PARKING AREAS. H-20 LOADING 8"-16" O/A LOAMY SAND SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS- UNLESS NOTED. LEACHING AREA REQUIREMENTS 8. 'ANY 'MASONARY UNITS USED TO BRING COVERS 'TO GRADE SHALL 16"-32" B LOAM SIDEWALL AREA 352.0_ S.F.. BE MORTARED IN PLACE. 9. .NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM_ AREA _3?-5-Q__ S.F. DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO 32"-108" C1 M-C SAND 10YR 5/8 LEACHING CAP.(BOT. & SIDEWALL)_353.0 GAL OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 10. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND `UTILITIES PRIOR TO ANY EXCAVATION. 108"-132". C2 MED SAND lOYR 6/4 NO H2O RESERVE LEACHING CAPACITY _353.0 .GAL. ENC'D ---- APPLICANT: DENNIS KERKADO DATE: 07/14/08 SHEET 2 OF 2 JOB # 1781