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HomeMy WebLinkAbout0249 MITCHELL'S WAY - Health 249 MITCHELL'S WAY,,HYANNIS A=290 047 1 � :j a -II G GE TOWN OF BARNSTABLE LOCATION `��L ��S �If��� SEWA # �`4 ` `'ILLAGE rv0 ASSESSOR'S MAP&PARCE—L�-o�� INSTALLER'S NAME&PHONE NO. y:� SEPTIC TANK CAPACITY 1600 LEACHING FACILITY:(type) �*\A, SAone_ (size) �X 1 NO.OF BEDROOMS OWNER PCO Gb- e_ PERMIT DATE: S 7 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 TP _`. gyp ow �� �' LA No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Bi-s $al *pstem Construction Permit Application for Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.914( W W j5[W A-� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a0ro 0q7 �Il Installer's Name,Address,and Tel.No. "� v7 -�D?/ Designer's Name,Address,and Tel.No. L tZOW11 MIA �f 6Co v\. 155- Qs Type of Building: Dwelling No.of Bedrooms Lot Size 16Ge 574 sq.ft. Garbage Grinder( ) . Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 gpd Plan Date N \3 Zkp 19 Number of sheets � ���j�e S'�Q&evision Date Title Size of Septic Tank O©O Type of S.A.S. �1e Description of Soil Nature of Repairs or Alterations(Answer when applicable) tf:L°� Date last inspected: Agreement: The undersigned agrees to ensure the construction and mai nance of the afore described on-site sewage disposal system in ' accordance with the provisions of Title 5 of the Enviro ental Cod d not to place the system in operation until a Certificate of Compliance has been issued by Bo of alth. �. f Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued ..�� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for .BOWPal *pstrm ctonstruction Permit Application for a Permit to,Construct( ) Repair, Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.a� rn �L�f.�rV "!r} i.` Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel _ of'✓f p o 0'-�7 Installer's Name,Address,and Tel.No. 7 �a s-0�07/ Designer's Name,Address,and Tel.No. �1 a,a 3 1L rt 4,'11 CC3 r ` s 4 L N Aj Type of Building: Dwelling No.of Bedrooms Lot Size ' sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3_31 gpd Design flow providedgpd Plan Date !2uf,a a0 6 Number of sheets ' Nevision Date Title Size of Septic Tank Won Type of S.A.S. Description of Soil )D,-k r, Nature of Repairs or Alterations(Answer when applicable) �[ Date last inspected: Agreement: The undersigned agrees to ensure the construction and mai enance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ental Cod and not to place the system.in operation until a Certificate of Compliance has been issued by s Bo of ealth. rs gri s Date # F Application Approved by Date Application Disapproved by Date for the following reasons .. Permit No. 4A241 Date Issued w , - - -,--------------_--------------------- --------------- ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( at "M,3 has been con cte in ac o ce e .o i . with the provisions of Title 5 and the for Disposal System Construction Permit N . Av' ed Installer L\_. Designer #bedrooms Approved design flow gpd The issuance of this permit sha not be c strued as a guarantee that the syste •wi 1�function* de ed. ,11 Date '> Inspector ______________________________ �_____-_____;_______----__._ '_-t--_-____-__________________ ______________ _________________________._ . No. Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 9ppstem Construction Permit Permission is hereby granted to Construct( ) Repair ) Upgrade( ) Abandon System located at QlAq LA/1�� t,c�,S ► F�y 6A_.n9 n9%�5 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons c'on must l/71eted within three years of the date of this permit. Date / Approved by J e � j � • t . Town of Barnstable: IKE tp P` ti Regula o. S rvice a" Ruh.irCl V-.'S611;.IntCHIIII U'ietrmr 1} b¢ Pitl�lic Health Divis:i+7n' AYFo-Mar" I honras'tMcKet n, Diredor , 200 M<rltt SWeet, (1yait'itisMA 02601 Office: 508 Sti2-=46t=t Fax: SON-7904530'.4 . I Installer & DesitYner.Certi-fication T+ornt 1 • t Date: �'�p6�9 selva c Pectin#O(t�g� RU((/ fltitietisor's.I�'I il�\P�:►rccl n F 1)csio;net , i`,�o r a, 7- L.oUG�(�L�W_3"t. � Intit<illt:t•: Address: ti 6gvf e Sp Address: C)n- 4 0� �Jr �9 ILt�w (MIf� Y VL� %Vits issued a hcrn,tt(0 Install a 16_ .. (date)'- I Iei`) 1 I ��n 4 { scpttc s:yste-ti>>at:. 2Aq. V Yt i�' Ge I�S based Ott a desi n"dfGt��fn'b • � ('�iddres's) / i _ �r d_(�___ UdZ:t7_ Vdtte clmu .(dest�ti4t�). = l TV I ccrtil'y that thc 'Septic System referenced above was installed sub>tantially accordim to i the deslgll: which tatty include 11.1111or approved Chan"I,es Sttch IS latclal 1:6)c86011 of the disti-ibati'o'n box ar dr'or sciatic .tank. Strip Out (tl required) was .inspected anal the soils ' were.frurtc'. satisfactory. § i y Y I certify that the Septic systcill re(erciced above was Installed .with major changes (i.e. 17tmter than 10' lateral reloc(ai.on of the.SAS or any .vertical relocation of illy component of the Septic's.ystetti) but in accordance with State & Local ReI-11.1lations. l'lti❑ revision or certitaed Its-built.by(icsiuild to ftillo\�r. Strip o.ut (i(reduired) was inspected and the soils f were foulid S".ittsfac�tory. 1 eclWi th::;t is ysteni refueliced-above \Yiis consta uc t iMice with tlae tel � -- Vy,A : : pro al leaec `ifIpplictrble) � `-- 'tsst� t IDAVI I: ti. D, r, CaUGN.ANOWR l st ' c r tit sire) No. 10p93 1 (Desikif S S {,nature) (Affix Detii ncr's Stamp Here) I It,F;.nSE' RE'17U11N TO BARNST,M31a14', PUBLIC IdF,AL`H DIVISION. CERT111-1C'A` F. ©Ir CONIPLIANCL. WILL NOT 13E ISSUED UN I II, BOTI-i THIS FORM AND AS- 13UILT CAR 1) ARE REC".I.IVED BY THE BARNS`T'ABI-E PUBLIC 11 EALTH DIVISION. THANK Y 0 U. l ):1Sepl ic'\Do ig ne ('crt l'ictmon Form Kcv 8-14-13.doc ' 1 l i LOCATION- � / , SEWAGE PERMIT M0. Y I l"LA G Eg `D Y 7 , IN �T LER'S NA E i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED tlOZS _ gs DATE COMPLIANCE ISSUED � � r � � - V'v No.. . ............... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........_0F....... .................... Aplifiration flir Dispaiial 10orks Ton.6trurtion "primit Application is hereby made for a Permit to Construct or Repair (J,<an Individual Sewage Disposal System at: A 'Z�00 Ag ...... ---------------------------------------------------------------------------------------------- oca n-Address or Lot No. ............ ................................................... apt ddr ss .... ..... ji __. _ # ..................................................................................... Installer Address Type of Building Size Lot............................Sq.,feet Dwelling o. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............_............... Showers Cafeteria ( ) P-4 < Other fixtures ----------------------------------- ------------------------------------------------------------------------------------------------------------------- Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width.--............. Diameter..........--.... Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No----------- ......... Diameter.................... Depth below inlet..................... Total leaching area............--....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................*--------­--------- aTest Pit No. I................minutes per inch Depth of Test Pit............_....... Depth to ground water..--.................... Test Pit No. 2................minutes per inch Depth of Test Pit--........._....._.. Depth to ground water..--.................... --------------------- ..................................................7---------------­--------------------------------I........................... 0 Description of Soil........ ............................................................................................................................... ------**------------------*--------*.............. -----------------------------------------------------------------*------------"-------------------- ----------"------------------------ .................... ................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable..... 7A--��- e...... ...................................................................................................................................... ................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'Ll'AIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by thn boa off h alth. Signed. ..... ----- Date ApplicationApproved By.............1—I.A.- ................................................................. ....................................... Date Application Disapproved for the following reasons:................................................................................................................ ..........................................................................................................................................7.............................................................. Date PermitNo....... ........................... Issued_....................................................... Date --------------------- --------- -----------I—_---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH .y Appliration for Disposal Works Tonstrur#inn Prrmi# Application:.is hereby made for a Permit to Construct ( ) or Repair (J4,1)"F¢an Individual Sewage Disposal System at s+, ------------ ' s Location•Address/ f or Lot No.-----�- --����� ������• f ... ......:... . ., _ Owner l f ..............Address .......... -............... .------ ...... ............................. - t�(.......................... J r r.......�f---_---:--:---F :...__... ....... •-•............. Installer Address Type of Building 0, Size Lot............................Sq. feet �U Dwelling-1 o. of Bedrooms.......................:. .....Ex Expansion Attic g -••---•------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons......................_..... Showers ( ) — Cafeteria ( ) dOther fixtures .----•--•-------------------------------•--•----................-----••-----•------•--- W Design Flow............................................gallons per person per day. Total daily flow-.----_------........_.._........_..........gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No..................... Width..................:: Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ... DDescription of Soil---.. n • .......x .. -----------------------------•--........--••--------.....---•--••.......•••..... U •-------------------•--....---...--•---......•-•--- ..----..........------•----...........----.......----.....-----•........ .-•--•---- --••••••---•-••-•-•-•-•••--...----•---•••--•••.--••- W ---•------•--•---- ------------------------•----------------------------••--•--------•-•------•-••------------••----••---•- Nature of Repairs or Alterations—Answer when.applicable =:.: .�� _-_.�? P PP : d..:_.................................................. U Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the/board of health Signed..::=.-- •t ; - ::r..: ...- ...................... t Date Application Approved B 't__.__.._:. ` z PP PP Y ...... = _-----•-•................•..................... ........................................ Date Application Disapproved for the ollounng reasons:---•---•.................•-•-•--•-•--••--•------.......-----------------......................_•••••......--- ........................................................ Date — PermitNo....... .................... ................... Issued.--.........-•....................................................... Date THE jCOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r .............' .......I .....OF.....°`� .. ..:.,. . �.'+"' �'* ......... ......... Tntifirate of Tomphaurr TJS,ISJTO CERTIFY, Thatsthe Individual Sewage Disposal-System constructed ( ) or Repaired (/-4- '" br t. p3 d t a,, y. . ..................... �:....... r ..:L..—.ta_.....•......._ ...r._._ �. _..._:.r...ax .......................... ...................... ....... Installer f ar y ----••• .............................................. ---•••-• ••----•--••- �.r - has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................0................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS!�GU NT THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. �::.....-•-• -- ....-----• Inspector--•---- ............... THE COMMONWEALTH OF MASSAC14 SETTS BOARD ,O,W HEALTH. OF....... '�.�r�-d �- /��2` �^ ........ `r No...., a1 ::.. G is ns .i ji g Tonsfr inn er 'o .....-- -- Permission s hereby granted to Construct .or Red ' ' 'dual Sewa a isposal t at No..._r X...................... � //r �' '. ''.................................... / • ........_..,a�_ as shown on the application for Disposal Works Construction Permit No. ................. Dated..__..... ..... ... ................... ................................... Board of th DATE.................. ......................................... r FORM 1255 A. M. SULKIN, INC.. BOSTON • • �1 Z 1 Town of Barnstable Barnstable , inspectional Services Department AN-A' micas 1 BARN STABLL I'b Public Health Division AlE.O�y A 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0000 1967 7597 May 30, 2019 PROCARE REALTY LLC 3 GRANLI DRIVE ANDOVER, MA 0 18 10 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 249 Mitchells Way, Hyannis, MA was inspected on 01/04/2019 and 04/30/2019 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: C Any portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ea I.S., CHO Agent of the Board of Health - Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\249 Mitchells Way Hyannis.doc IKE Tp� Town of Barnstable • anxrisrABLF, b 9 p Inspectional Services Department ArfD�Y Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"X"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool o Structurally unsound,septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or ' clogged SAS or cesspool )Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments : 249 Mitchells Way Property Address t�^' Procare Realty eq Owner Owner's Namfa information is Hyannis ✓ Ma 02601 1/4/2019 &4/30/2019 required for every Y page. Cityrrown State Zip Code Date of Inspection s 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. Inspector Information Sl,,t ($ 0411I on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co Company Address Centerville Ma 02632 Cityrrown State Zip Code � 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function .and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. . ❑ Needs Further Evaluation by'the Local Approving Authority 4. ® Fails 4/30/2019 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way V Property Address Procare Realty Owner Owners Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owners Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms,not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary, (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owners Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 0 ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [Phis 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 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page., CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat; or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office:of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ Z Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs.of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc"rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection , D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 3 months Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ®' No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts t� = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: unknown Were sewage odors detected'when arriving at the site? ❑ Yes ® No 5. 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.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6„ Distance from top of sludge to bottom of outlet tee or baffle T Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form !� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level_: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: . Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 249 Mitchelis Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis . Ma 02601 1/4/2019 &4/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with 6" standing water. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer.: Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owners Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 1Y 01i'07 � AZ 27 l3Z 2� (33 3 Z A� s/ r3 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis . Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high 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: using laser transit and taking measurement of pond level and bottom of leach pit it was determined that the bottom of pit is approx 8" in the groundwater level. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Ir 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 249 Mitchells Way Property Address Procare Realty Owner Owner's Name information is required for every Hyannis Ma 02601 1/4/2019 &4/30/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 YOU WISH TO OPEN' A BUSINESS? For Your information: 'Business certificates (cost.$40.O or 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the.Business Certificate that is required by law. — DATE: Fill in please: APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: ;,0 �0� TELEPHONE # Home Telephone Number o. % S - :.. . .... 'NAME OF NEW BUSINESS.:.., l l/P = ,�"q�('/;l: ._ -.ivy"i,:,,�� TYPE OF'BUSINESS " . � '�. U j�,•r��j� IS:TIS:AOMIw'OCCUPIa SON?:::::; >a YE ENO. iv _.. ,ADDRESS OF,BUSINESS ' T `';`...: — R /!l MAP/PA- CEL NUMBER , •� ..7, :(/lssessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main.St. - (corner of Yarmouth Rd. &-Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. \ 1. BUILDING COM ISSIO ER'SOFF E This individu I h e o an per it r uire ants t'at pertain to this type of busines�)UST COMPLY WITH HOME'OCCUPATION RULES AND REGULATIONS. FAILURE TO Au horiz n g COMPLY MAY RESULT IN FINES. OMMENT r a 2. BOARD OF H LTH This individual has A6� " EGO of thy permit r quirements that pertain to this type of business. buture MUST` OMPLY WfIN ALL COMMENTS: HAZARPOUS:MATERIALS RErU.LATili*S 9. CONSUMER AFFAIRS(LICENSING AUTHORITY] This individual has been informed of the licensing'requirements that pertain to this type of business. Authorized Signature** " COMMENTS: lj Dater' /a�/I TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: -- $'121416W .art//w BUSINESS LOCATION: y' � ORY MAILING ADDRESS: 'G/' /12CG/ l�� G1/ lj ry« lMe w LAMOUNT- TELEPHONE NUMBER: C� CONTACT PERSON: lgnlle i EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: _ gv_-:�e -�e� c ��S afr'� /l INFORMATION % RECOM`M`ENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants _F Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels __.(including chloroform, formaldehyde, --> -Paint&varnish'removers,'deglossers __ hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers X (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers - ; Windshield wash W o,OCUA WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS bPPlicant's Signature y Staff's Initials 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 EREIVED Property Address: 2 4 9' Mitchel 1 s .Way Hyannis, MA . ' Owner's Name: Jennifer Ramos 2001Owner's Address: same DEPTABLE , Date of Inspection: �_ j Name of inspector: (please print)Jdi 1 I i am E_ •Robi nson- `Sr Company Name: William E. Robinson , Septic,.,Service Mailing Address: P O Box 1089 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.I am a DEP approved system inspector pursuant to Section 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:,f 2 Date: !2-. 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 249 Mitchells Way Hyannis Owner: Ramos Date of Inspection: 2.-ky-L 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys 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. mments: B. S stem 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)it the for the following statements.If"not determined"please explain. e 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,Ank is replaced with a complying septic tank as approved by the Board of Health. •A me 7 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica ' g that the tank is less than 20 years old is available. ND ex lain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or ob ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appro al 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 ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A° ' CERTIFICATION(continued) Property Address: 249 Mitchells Way Hyannis Owner: RgLmos 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 fa ing 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 surfacer water' Cesspool or privy i within 50 feet of a bordering vegetated wetland or a salt marsh C s P P �'Y g g _ 2 System will fail unless the Board of Health(and Public Water'Supplier;if any)determines that the stem 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-.., _F The system has a septic tank and SAS and the SAS is within a Zone 1 of a'ublic 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. Other: .3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 249 Mi ch 1 1 s, Way Hyannis Owner- Ramos Date of Inspection: X- D. yytem Failure Criteria applicable to all systems:. You ust indicate"yes"or"no"to each of the following for all inspections: Yes o 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 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. E. L e Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You st indicate either"yes"or"no"to each of the following: (The llowing 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 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 bas famed.The owner or operator of any large system considered a signi scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3 .The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 249 M i t ch P 1 1 c Way Hyannic Owner: R a mn c Date of Inspection: ;t ct-6- 0 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? V _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) c/ Was the facility or dwelling.inspected for signs of sewage back up? Was the site inspected for signs of break out 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 for the condition the o 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. -1 Z- Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J . 5 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 249 Mitchells Way Hyannis Owner: Ramos Date of Inspection: eL'Al•—D l FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): d Number of current residents:1�1 — Does residence have a garbage grinder(yes or no):Ld Is laundry on a separate sewage system(yes or no):,L [if yes separate inspection required] Laundry system inspected(yes or no): 0 Seasonal use:(yes or no): L.jj Water meter readings,if available(last 2 years usage(gpd)): 2000 52,500 gal. Sump pump(yes or no): i D 1999 33, 000 gal. Last date of occupancy: =0 1 C MERCIAL/INDUSTRIAL Type f establishment: Desig flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no): Indus ial waste holding tank present(yes or no): Non- anitary waste discharged to the Title 5 system(yes or no): Wat meter readings,if available: L date of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: l ei 9 '7 Was system pumped as part of the inspection:(yes or no): A,0 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 Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attaci 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)anj source of information: 5, 15 Were sewage odors detected when arriving at the site(yes or 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: 249 Mitchells Way Hyannis Owner: Ramos Date of Inspection: B LDING SEWER(locate on site plan) Dep below grade: Mat rials of construction: cast iron _40 PVC other(explain): Dis nce from private water supply well or suction line: C ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: Y (locate on site plan) Depth below grade:_I k Material of construction:_Vconcrete_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) ti ►i Dimensions: Sludge depth: V 5 Distance from top of sludu to bottom of outlet tee or baffle: Scum thickness: 1 y�- 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 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.): / , / � (� , GR SE TRAP:_(locate on site plan) Depth b low grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain . Dimensi ns: Scum th ckness: Distanc from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Comm nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rela ed to outlet invert,evidence of leakage,etc.):. 7 4, Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 249 Mi tche 11 s Way Hyannis Owner: R�mpg Date of Inspection: X—9-G—a I HT or HOLDING TANK: (tank.must be pumped at time of inspection)(locate on site plan) Dept below grade: Mate 'a]of construction: concrete metal fiberglass_polyethylene other(explain): Dijai sions: Caty: gallons De Flow: gallons/day Alpresent(yes or no): Allevel: Alarm in working order(yes or no): Daf last pumping: Coents(condition of alarm and float switches,etc.): V 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.): /b PUMP HAMBER: (locate on site plan) Pumps i working order(yes or no): Alarms n working order(yes or no): Comm is(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) Property Address: 249 Mitchells Way Hyannis Owner: Ramos Date of Inspection: ;2--';L L -b SOIL ABSORPTION SYSTEM(SAS): >/(locate'on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: I 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.): Ion v' L- l Jw i CESSPOOL (cesspool must be pumped as part of inspect,ion)(locate on site plan) Number and con figuration: Depth—top of li id to inlet invert: Depth of solids la er: Depth of scum lay r: Dimensions of ces pool: Materials of cons ction: Indication of go dwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ( cate on site plan) ' Materials of c struction: Dimensions: Depth of sol' s: Comments(n a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 249 Mitchells Way Hyannis Owner: Ramos 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. 10 ,Page 11 of 11 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 249 Mitchells Way Hyannis Owner: Ramos Date of Inspection: .. 1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L 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 M_Mt describe how you established the high ground water elevation: o n. riS �n�- _T �/' D l�t� x. 11 ti. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 WILLIAM F.WELD TRUDY COXE l� ff Secretary Governor ARGEO PAUL CELLVCCI AVID B. STRUHS Lt. Governor COmnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM IlYSP IOR M _0. N .PART A t 'CERTIFICATION , iroW 2 199 c F, Prperty Address 1 C�Y� 5 (q Addr Owner: 4i�t -Y'- T tit Date of Inspection: 5 `ci 6Zlob C (If different) \��� IL►Avrc Name of Inspector: tAj t,j 1 am a DEP approved system inspector pursuant to Section 15:340 of Title 5 (310 CMR 0100jo Company Name: T 1 L Mailing Address: r�( X a.��'��� ��r t Telephone Number: e;CN'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: Y Passes Conditionally Passes r. _ Needs Further Evaluation B the Local Approving Authority Fails P , L 1 Ins ector's Signature:_ Date: �U' 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 iystem 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] SYSTEM 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. COMMENTS: S STCvn m- ca-U 1;�V.,_ A-c=c 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 conforming septic tank as approved by the Board of Health. (revised 04/Z5/97) p2ge 1 of 10 t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in t distribution box is due to broken or obstructed pipe(s) or d•.te to a broken, settled or uneven distr'bution box. The system w' I pass inspection if(with approval of the Board of Health). Describe observatigns: broken pipe(s) are replaced obstruction is removed distribution box is I:velled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Heal in order to determine if the system is failing to protect the public health. safety and the environment. I 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMENFES THAT THE SYSTEM IS NOT FUNCTIONL;G IN A . MAti'\'ER WITCH WILL PROTECT THE PUBLIC HEALTH r SAFETY A:tiB THE ENVIROMNIEN7: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetatetland or a salt marsh. Z) SYSTEM NVILL FAIL UNLESS THE BOARD OF HEALTH ( D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERtiIIIrES THAT THE SYSTEM IS FUNCTIONING IN MANNER THAT PROTECTS THE PUBLIC HEALTH A.\-D SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption syste (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 syste and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption syste and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption syste 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 c iform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (a proximation not valid). 3) OTHER (revised 04125/97) Page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determi,.ed that the system violates one or more of the following failure criteria as defined in 310 C R 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be ecessary 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 `verloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due,to an overloaded or c gged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less th 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or.ob rutted pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is.below the h h groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface .water s, pply 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 feei of a private wat r supply well. " Any portion of a cesspool or privy is less than 100 feet but great than 501eet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed o be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitro n and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the.following: The following criteria apply to large systems in addition to the cri ria above: The system serves a facility with a design flow of 110,000 gpd o greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of a following conditions exist: Yes No. the''system is within 400 feet of a surface drinki g water supply the system is within 200 feet of a tributary to surface drinking water supply the system is located,in a nitrogen sensitive rea (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 sys m and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult th 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 Property Address:{ "%T_C_V1 _.1 k g Owner: Date of Inspection: t 5\4 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No um in P information was provided by the owner, occupant, or Board of Health. Pumping J _ 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, naterial 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: 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. 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)] (revised 04/25/97) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2y"l Owner: Date of Inspection:c� t 5 y cl 1 \ FLOW CONDITIONS RESIDENTIAL: Design flow: 3� d Q.p^d./bedroom for S.A.S. „ Number of bedrooms:' Number of current residents: e:)Z m' Garbage grinder (yes or no): Laundry connected to system (yes or no): � Seasonal use (yes or no):_E,,� Water meter readings. if available (last two (2) year usage (gpd): 'C—) Sump Pump (yes or no):_t---) Last date of occupancy: w COMMERCIAL/INDUSTRIAL: Type of establishment Design flow: eallons/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 readines. if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL'IIS"FORti1ATION PU'MPLtiG RECORDS and source of inform tion System pumped as part of inspection:'(yes or no)_N N, If yes, volume pumped: eallons 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) I/A Technology etc. Copy-of up to date contract? :Other A 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 04/25197) Pere 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: St 5 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 joints, venting, evidence of leakage, etc.) SEPTIC TANK:—W5 (locate on site plan) tr Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list ace _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: `O +� Sludge depth: \G" Distance from top of sludve to bottom of outlet tee or baffle: o2 f Scum thickness: t` Distance from top of scum to top of outlet tee or baffle: \6" �t Distance from bottom of scum to bottom of outlet tee or Eaffle: V—k How dimensions were determined: t2�:•a t .v�Q� Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outle: inven. structural in[e rity. evidence of leakage. etc.) N� t ` � �C GREASE TRAP:_&D (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: (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.) (reriwdl 04/25197) P2ge 6 of 10 r SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM W PART C SYSTEM'I 'FORMATION (continued) Property Address: a�5 H J-CV1_t_0S Owner: Date of Inspection: I TIGHT OR HOLDING TANK: _ (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 level: Alarm in workinc order Yes: No Date of previous pumping: : Comments: (condition of inlet tee. condition of alarm and float switches. etc) )ISTRIBUTION BOX:L'sj�S (locate on site plan) - Depth of liquid level above outlet invert_ Tw'CU Comments: note if level and distribution is Huai. evidence of solids car over,1gvidence of leakage into or out of box, etc.) gi zi l� Q t\` �,Iz S Q0 C,cT O Gck %r T PUN P CHAMBER:' t (locate on site plan) m" 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 04/25/97) P2ge 7 of 10 r SUBSURFACE SEWAGE DISP OSAL SYSTEM INSPECTION FORM PART C c, SYS' EM INFORMATION (continued) Property Address: Owner: Date of Inspection:$�s l�b ABSORPTION SYSTEM (SAS): SOIL ABS L�,"� (locate on site plan, if possible. excavation Hut required. but may be approximated by non-intrusive methods) If not determined to b;l present, explain: ' Type: leaching pits, number:-(ox(� leachin¢ 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, condition of vegelion tc.) t it ti C11 V, CESSPOOLS: N� (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, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of Fonding, condition of vegetation, etc.) (revised 04/25/97) P2ge 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tiI PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to ai,least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Ski i z 2 (revised 0..125197) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: �(� i 4 L Depth to Groundwater �S 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.) i� Determine it from local conditions Check 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. titust be completed) (revised 04/25/97) P2ge 10 of 10 TOWN OF BARNSTABLE LOCATION c��1r1 `QiJC, aVS,, UVc?t�A SEWAGE # VILLr".GE ASSESSOR'S MAP &LOTA (:), b INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l yK d A of e LEACHING FACILITY: (type) (size) NO.OF BEDROOMS _ BUILDER OR OWNER bo MO& $DATE: � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and ei4t-t \S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N iPt Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) iy�t4 Feet Furnished by Q-X�-LC 3a� HYANNIS. MA . NOT TO ' O SCALE THIS I5 A N . WAY D.. - . p H rn . PLAN. UT USE COLOR.PLAN ONLY A OWED 0 - MM FOR INSTALLATION - �� FULL DETAIL IS BEST 4 U" — /O 05tABLE GIS DAT�y VIEWED IN rn X I FULL COLOR WEST M A IN STREET ELEVATION 26. 12 p OF FOUND., -\O'f s� _ 28.. 29 oa LEGEND 27 2 b s�lE �_- .a„ � SEPTIC COMPONENTS 25 O �. 1 EXISTING 21 22 23 lb eft + 1 TIC TANK GAL r ® ,o . : �� SEPTIC 20 r INSTALL 19 v PAVED DRIVEN/AY + 1000 GAL f oN PUMP ry n R CHAMBER. I pp q� EXISTING LO 110 - o'r /. z --— . .AREA 0654 sf+ 3 I .LEACH PIT/ (jam 1:: 0 - 2 , . $ PLAN 800 82 PAGE/' 9 `L/J O �e 1 � m � �� _B DISTRIBUTION BOX n a Assn AP 290 rc 47 0 �Fc, � IS ft 1r i :j VENT TEST PIT d P PIPE d(\p� EXISTING LEACH PIT TO BE „ Q G M I N LM A L I / PUMPED & REMOVED. REMOVE J GRADING Oa E'" �W' v ~ a ��� �� r R o r o s E "T�0 o ""4 0` ALL ASSOCIATED CONTAMINATED- �, Ql SOILS & REPLACE WITH CLEAN 3 �L�.y G : R TITLE 5. p,, I / "'.. � ." MEDIUM SAND PER 29 [� 27 26 28 PROPOSED. SOIL TA� WATER LINE . 2 167 ft +- 24 25 ABSORP I ION 2 i �/ 7- A,� WATER GATE O .' 4 1020 21 S I S I EIVI -SEE DETAIL OAS TINE 100 ft FROM POND -SON BACK OAS GATE O. OVERHEAD WIRE OH OL ITY PLA ��H2OF 44ss9 P`ZN.OF Mgss9 E N DAVID OyGJ, o DAVID �tioJ SCALE: 1 in = 20 ft D. D. - - �+ COUGHANOWR COUGHANOWR - - 0 20 40 . No. 1093 No. 461 J'01 T SEWAGE DISPOSAL • 'PF fLO '9P O TO SERVE SYSTEM I .GPo EALNL INc FR • e• O IO 20 lI , GISTE� SO/( OVE��� [s 'U0 NIT 1 U A - •' PRINT ON 11 x 17 in PRO�ARE PAPER FOR PROPER SCALE' REALTY L L.C.., ri . � a`• `.� • • � OWNERfSI OF RECORD r ° 249. MITCHELLS WAY HYANNIS.. THIS PLAN IS INTENDED SOLELY FOR INSTALLATION.OF THE SEPTIC SYSTEM - - 155 Geo Ryder RCI S P - . . . . _. MA ' DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE.PROPERTY INCLUDING � � � . . - � . . - CI10tI10P71, MA OZ633 - _--- _'PLACEMENT OF ADDITIONS,-SHEDS, FENCES OR SWIMMING.POOLS.. OWNER - - PROPERTY ADDRESS - SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. DQVIdCOUGHOtrt1OII.COm DATE: DUNE �3, 2019 — �� loe� ETE-4391 �Bcoe, 508 . 364 0894 PG.U Oo iL TE T UoOG ''. am U& am 1000 GALLON SEPTOC TANK 10 0o GALLOnN PUMP C�HAM BEAR DOSS T RIBUT§Oo nN BOoX UDB-3 H20Y SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE #461 EXISTING UNIT - DIMENSIONS & DETAIL DIMENSIONS AND DETAIL ELECTRICAL PERMIT NEEDED DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL WITNESSED BY: DAVID STANTON. HEALTH DEPT. TANK TO BE PUMPED DRY AT TIME OF INSTALLATION FOR PUMP SYSTEM AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN TEST PIT I NO GROUNDWATER ENCOUNTERED AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL TO PERC AT 54 In - 3 MIN/INCH IN C SOILS NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. BUOYANCY I in ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER REPLACE WITH A NEW CALCS TAPER SCALE INCHES HORIZON TEXTURE (MUNSELL) MOTTLES L 1500 GALLON TANK MI in 1 in SEASONAL HIGH C MIN 29.25 0-6 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE TAPER IF CRACKED. ROTTED GROUNDWATER = 20.05 0 ® -► OR OTHERWISE 27.00 6-27 Bw LOAMY SAND 10 YR 4/2 NONE LOOSE ,� COMPROMISED. BOTTOM �AMBER = 18.58 0 � C � N FROM l = = -' 27-120 C MEDIUM SAND 10 YR 6/4 NONE LOOSE �co TANK b TO 19.25 C DEPTH OF WATER p; ^ d SAS p DISPLACED = 1.47 ft �(\ 0 co EXTERIOR DIMENSIONS OF \0 o TEST PIT 2 NO GROUNDWATER ENCOUNTERED ,I NOT UNIT = 8.5 ft x 4.83 ft �� 0 b ln STONE SAS E 3 MIN/INCH IN C SOILS TO 60 x 4.83 x 1.47= 60.35 cu 8 ft-6 /n A 21 2� CROSS SECTION VIEW ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER � 60.35 cu ft x 7.48 = 452 go/ �n INCHES HORIZON TEXTURE (MUNSELL) MOTTLES SCALE 452 x 8 Ib/ go/ 3616 # USE SHOREY PRECAST 29.40 0-8 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE �� PUMP CHAMBER WEIGHS 8240# ST-1000 H-10 26.90 8-30 Bw LOAMY SAND 10 YR 4/2 NONE LOOSE 8 Y PUMP CHAMBER WILL NOT FLOAT OR EQUIVALENT 30-120 C MEDIUM SAND 10 YR 6/4 NONE LOOSE ft-6 I/ ���L�O�/� STONE TO BE DOUBLE WASHED & 19.40 in A TANK TO BE CERTIFIED WATERPROOF ALL ELECTRICAL CONNECTIONS L n . ■�v FREE E IRONS. FINES & DUST. & WATERTIGHT BY MANUFACTURER TO BE MADE OUTSIDE CHAMBER INLET OUTLET CONTROL PANEL TO CONSIST OF AUDIBLE AND VISUAL ALARM ON IFI EL® DIMENSIONS PLACE END CAPS ON LINES COVER COVER INDEPENDANT CIRCUIT AND TO BE LOCATED OUTSIDE DWELLING. AND DETAIL WITHOUT VENT. D EGM0 �I � L ��L A Tn O N INSPECTION PORT WITHIN 3 In w LL�. ll �3 IN DROP LINE USE BARNES SE411 PUMP 0.4 HP, 115 V. 1750 RPM OF FINAL GRADE. -► PASSING 1-112 in SOLIDS DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD FROM 10 in - l4 TO PROVIDE 114 in INSTALL QUICK COVER SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS BUILDING D-BOX WEEPHOLE TO DISCONNECT TO USE EXISTING 1000 GALLON SEPTIC TANK IF IN 48 in DRAIN PIPE AFTER COUPLER GRADE SOUND STRUCTURAL CONDITION. IF NOT. INSTALL LIQUID GAS PUMP CYCLE INTO RISER z N NEW 1500 GALLON SEPTIC TANK. BAFFLE TO m PUMP CHAMBER: INSTALL 1000 GALLON UNIT LEVEL D-BOX CID 9 Oz --► STORAGE = 500 GALLONS -► cn 3ft DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. FROM WEEP .r ^� b fn STONE BASE IF NEW SEPTIC ALARM ON 24 in HOLE Z SOIL ABSORBTION SYSTEM: SEPARATION BETWEEN INLET & OUTLET TANK � 0 THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE TEES NO LESS THAN LIQUID DEPTH CHECK SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES PUMP ON /6 in VALVE PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. CROSS SECTION VIEW THE 25 ft x 18 LEACHING FIELD PUMP OFF 12 in DEPICTED BELOW CAN LEACH: BUOYANCY CALCS 2S ft SEASONAL HIGH GROUNDWATER = 20.05 6 In STONE BASE BOTTOM AREA = (25 x 18) = 450 sq. ft. BOTTOM OF SEPTIC TANK = 19.13 SIDEWALL AREA =0 0 sq. ft. DEPTH OF WATER DISPLACED = 0.92 DOSING = 83.3 GAL/CYCLE = 4 CYCLES/DAY DISCHARGE HOLES NOT SMALLER THAN 3/8 In. NOT GREATER THAN 5/8 in. TOTAL AREA = 450 sq. ft. EXTERIOR DIMENSIONS OF UNIT = 8.5 ft x 4.83 ft STORAGE = 500 GALLONS , 330 GPD REQUIRED FLOW CAPACITY = 0.74 x 450 = 333 gal/day 8.5 x 4.83 x 2.15 = 37.8 cu ft x 7.48 = 283 GAL INSTALL A 25 ft x 18 ft x LEACH FIELD AS CONFIGURED 283 x 8 Ib/ go/ = 2264 # CROSS SECTION VIEW BELOW. FLOW CAPACITY = 333 gal/day WHICH EXCEEDS SEPTIC TANK WEIGHS 8240# THE 330 gal/dog REQUIRED FOR A THREE BEDROOM DESIGN. SEPTIC TANK WILL NOT FLOAT ,� ,;, -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK.J�IJ�V\1JI L OW ^ On -ALLTHEE MINIM M REQUIREMENTSONENTS INSTALLED HOFALL MEET �J '((JJu��� L E MASSACHUSETTS TITLE 5 SEPTIC O CODE (310 CMR 15). -INSTALLER TO VERIFY LOCATIONS OF ALL TOP OF FOUNDATION RAISE COVERS TO .WITHIN ALL PIPE TO 4 in BE SCH. 40 PVC* UNDERGROUND UTILITIES BEFORE EL = 26.12 +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN L/4 EXCAVATING FOR SYSTEM. -ECO-TECH RAPID RESPONSE RECOMMENDS 29.0 THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC 201n WATER 12 jp *`PIPE FROM PUMP CHAMBER TO PUMPING OF THE SEPTIC TANK. 24.8 TI�O GRADE T COVER D-BOX MIN D-BOX SHALL BE 2 in PVC WITH �oF -SYSTEM VEHICULAR LOADING. DOONOTTPARKNOR 24 25 TEE 26.11 THRUST BLOCKING AT BENDS. DRIVE VEHICLES OVER SEPTIC SYSTEM. EXISTING REFER TO DETAIL BOX 26.10 a b d oo c o��p4oR0 b vo vo a ae b°¢og o 44pQoo ?6 gooa�oo 0 0 o babe o Oooa o a 9' 1000 GALLON PROP03ED g0000000�Foo oo, bo a«o�o� 000P° o °tea o.aobo EXISTING 6 in 25.93 SEPTIC TANK 23.30 �eoeb�a oe�oa�o�a� moo«od000aQos7�agaa a M�j I - REFER TO DETAIL BOX EXISTING PUMP OCH M ER 22.75 STONE LEACH" _ D Al POND ELEV = 18.95 INDEX WELL MIW-29 EXISTING 1913 25.78 -REFER TO DETAIL BOX ZONE C 23.00 18.508 25.15 READING DATE MAY. 2019 6 in STONE BASE 3-7 ft Ln READING 6.46 EXISTING 10 ft 3.5 f t ADJUSTED SEASONAL ADJUSTMENT 1.1 HIGH GROUNDWATER - 20.05 ADJUSTED GW 20.05 SEWAGE DISPOSAL SYSTEM PLAN 249 MITCHELLS WAY HYANNIS, MA JUNE 13. 2019 ETE-4391 PG 2/2