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HomeMy WebLinkAbout0350 MITCHELL'S WAY - Health 350 Mitchells Way Hyannis A=291 —230 I i i ii I I 1 �I o i i -TITLE'S ~ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Addres 350 Mitchell's Way Hyannis,Ma 02601 Owner:Vanaiee Medeiros Owner's Address: 8 Timberlane Dr Mashpee,Ma 02649 Q� Date of Inspection: 11/22/05 C'/ Name of Inspector:(please print) David J.Burnie Company Name: David J Burnie&Sons Septic Services Mailing Address: 307A Commerce Park N South Chatham,Ma,02659 Telephone Nu mber:umber: 508-432-7420 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: t Passes JL Conditionally Passes _Needs Further Evaluation by the Local Approving Auth1has Fails � �Inspector's-Signature: cr 11/22/05cr-,The system inspector shall submit a copy of this inspection report to the Approving Authorityd of ea Health or DEP)within 30 days of completing this inspection.If the system is a shared system a r"i 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 Conditional pass subject to repair or replacement of leaking septic tank ****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. W9 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - 1 CERTIFICATION(continued) Property Address: 350 Mitchell's Way Owner:Vanaiee Medeiros Date of Inspection:11/22/05 Inspection Summary:Check A,B,C,D or E I ALWAYS complete all of Section D A.System Passes: I have not found any information which indicates that any of the failure criteria described m 310 CMR 15.303 or in 310 CMR 15.304 exists.Any.failure criteria not evaluated are indicated below.Comments: sample B.System Conditionally Passes: X 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 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 tank ears old*or the se tic y p (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfdtration 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 bog. System will pass inspection if(with approval of Board of Health): _broken pipes)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 X repair or replacement of leaking septic tank ND explain: �1� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 350 Mitchell's Way Owner: Vanaiee Medeiros Date of Inspection: 11/22/05 C.Further Evaluation is required by the Board of Health: _Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1.System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has aseptic tank and SAS and the SAS is within a Zone I ofa 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 Mitchell's Way Owner: Vanaiee Medeiros Date of Inspection: 11/22/05 D.System Failure Criteria applicable to all systems. You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than lf2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 Systems: To be considered a large system the system most serve a facility with a design flow of 101,000 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 H 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 350 Mitchell's Way Owner: Vanaiee Medeiros Date of Inspection: sample Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No N/A _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Has large volume of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back ur. X _ Was the site inspected for signs of break out? X _ Were all system components,including the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bates or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _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 determined based on: P y (SAS) has been 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)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,SYSTEM INFORMATION Property Address: 350 Mitchell's way Owner: Vanaiee Medeiros Date of Inspection: 11/22/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):Unknown Number of bedrooms(actual):2 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): Number of current residents:None Does residence have a garbage grinder(yes or no):Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no):No Water meter readings,if available(last 2 years usage(gpd)):None available Sump pump(yes or no):No Last date of occupancy..Unknown T COMIKERCIAL/INDUSTR]AL Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons✓sgfi,etc.) Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:N/A throueh Board of Health 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 X '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) hmovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be ' obtained ITom system owner) _Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information Installed 1998 Were sewage odors detected when arriving at the site(yes or no):No v � OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Way Owner: Vanaiee Medeiros Date of Inspection: 11/22/05 BUELDING SEWER(locate on site plan) Depth below grade: 1' Materials of construction:oast iron X 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Ok t. SEPTIC TANK: Yes (locate on site plan) Depth below grade: 61, Material of construction: X concrete_metal_fiberglass polyethylene_other(explain) If tank is metal list age:_is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:1500 eal Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:Estimated Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet invert evidence of leakage,etc.): Septic tank leaking. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: .Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert.evidence of leakage,ctc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Way Owner: Vanniee Medeiros Date of Inspection: 11/22/05 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: gallonstday 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: Yes (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 canyover,any evidence of leakage into or out of box,etc.): Ok PUMP CHAMBER:_(locate on site plan) -. Pumps in working order(yes or no):_ Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Way Owner: Vanaiee Medeiros Date of Inspection: 11/22/05 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required) If SAS not located explain why: Type _Leaching pits,number:_ _Leaching chambers,number._ X Leaching galleries,number. 3 maximizers per permit 98-56 see attached _Leaching trenches,number,length:_ _Leaching fields,number,dimensions:_ _Overflow cesspool,number: _Innovativetalternative system.Typetname of technology:_ Comments(note condition of soil,signs of hydraulic failure,level ofponding,damp soil,condition of vegetation,etc.): 5"standine water 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 or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Do OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Way Owner. Vanaiee Medeiros Date of Inspection: llR2/05 SITE EXAM Slope Minor Surface water No Check cellar D_yr Shallow wells No Estimated depth to ground water 12+ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-1f checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database- explain-You must describe how you established the high ground water elevation: See att2ehed.eoiij6dor report dated:2l7/Z000 BIRD didn't have test hole info to support prior report.See attached*..... repot dated:06JZa/02 eao Ted:See below mamma. � W � 0Lv�L/Q- �.�-3.3 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Way . Owner. Vanaiee Medeiros Date of Inspection: 11t22105 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewav disposal system including ties to at least two permanent reference landmarks or bend Locate all wells within 100 fed.Locate where public water supply enters the building. Q� 1 ,L Q - r W45, Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Mitchell's Wu $�annis owner: T eonard Green ; Date of Inspection: Tune 2002 _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 12+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed —X— Observed Site(abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of health-explain: Checked local excavators, installers-attach documentation) —X Accessed USGS database You must describe how you established the high ground water elevation. C'Mparicon of USCIS TWngraphy maps and surface water elevation data chows site to be over 12 feet above gro mdwa er_ Apglyjngan adjustment factor of 4.8 feet(Index well Al W-230,-zone D_ May 2002 level =24 1), demonstrates that bottom of SAS is abovea justedLhigh gg=dwater I V 1 �Q 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinied) ;OPWWAddress: 350 Mitchells Way, Hyannis Owner: Robert Gonella Date of Inapwdon:2-f-eZ NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells x Estimated Depth to Groundwater.2OFeet Please indicate all the methods used to determine High Groundwater Elevation: 0 tained from Design Plans on record OObserved Site(Abutting property, observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps _Checked pumping records Checked local excavators, installers Used USGS Data Describe how) you established the High (Groundwater Elevation. (Must be completed) Y Y V revised 9/2/98 P2gCItof1I i NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) L William E.Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 350 Mitchells_Wayjyannis AU meets all of the following criteria: * There are no wetlands within loo feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system- * There is no increase in flow and/or change in use Proposed- * There are no variances requested or needed " bottom of the * proposed leaching facility will be located with 250 feet of any wetlands,thebo If the g ty P o� proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED:, j v DATE o� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 0 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). No.. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 3pplicotton for �Dtgo!go.Y 6pgtem Cowgtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.3_j ��l��/JJt��� ly� Owner's Name,Address,and Tel.No. Assessor's Map/parcel / 27y Yea J YZT Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. -17W V),P 0 .5' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tit 5 f the Environme tal Code and not to place the system in operation until a Certificate of Compliance has been issued by this ar of e t Signed Date /0 -I Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. r Date Issued No. . � ! Fee " THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for IDigpoga[ *patent Cow5tructf on Permit Application for a Permit to Construct( ) Repair O Upgrade(,) Abandon( )' ❑ Complete System ❑Individual Components Location Address or Lot No. 3 j d �/f��J���•S Owner's Name,Address,and Tel.No. Assessor'};Map/Parcel Installer? Address,and Tel.No. 31f�. Designer's Name,Address and Tel.No. �X�L�� �' �!�✓fir✓/ g�- �S a._.___._..-- /1/�f� ,a— 7 ZO 1 pefof Building: D*elling No.of Bedrooms Lot Size sq. ft. Garbage Grinder 4v,Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures «4 Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date i Title Size of Septic Tank Type of S.A.S. ; Description of Soil Nature of Repairs or Alterations(Answer when applicable) l 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 Tit 5 f the Environme al Code and not to place the system in operation until a Certificate of Compliance has been issued by this/Spar of e Signed y Date /Z Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. ` r Date Issued —————————————————————————————=" _— —————— l�i e THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by at /Yl i �C%AO //S t, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. O 15 &07 dated Installer -p Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will funciion `as desig d/_) B Date r3 i Inspector -------------------------------------------- NO. O Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS U� =45poot *pgtem Construction Permit Permission is hereby granted to Construct ( ) / /Repair ( ) Upgrade ( ) ' Abandon, ( ) System located at C m% s�-[��- - ��� Y , V 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: Constructi4 m st be completed within three years of the date of this p it. , Date �� Approved by ECO-TECH i 5� ENVIRONMENTAL W W W.ECO-TECH.US THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION (revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 350 Mitchell's Way Hyannis JUN 2 4 2002 Owner's Name: Leonard Green ABLE Owner's Address: 350 Mitchell's Way TOWN OF BAR HEALTH DE TPT.. Hyannis Date of Inspection: June 21, 2002 MAP Name of Inspector:(Please Print) David D. Coughanowr, R.S. PARCEL ' 1 Company Name: Fco-Tech Environmental LOT Mailing Address: 43 Triangle Circle — Sandwich, MA 02563 Telephone Number: (508) 364-0894 I 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature �� 6nA, k Date: J V N F It, 2-00 e 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 Inspector's Note=_> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 INSPECTION SUMMARY: Check A, B, C,D or E/ALWAYS complete all of section D: A] System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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, or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of 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 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 ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 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 s failing to protect public health, safety and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health (and public water supplier, if any) determines that the system is functioning in a manner that protects the public health, safety, and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 by a DEP certified laboratory, for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3) OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 D) System Failure Criteria applicable to all systems: You must indicate either "yes" or "no" to each of the following for alb inspections: I have determined that one or more of the following failure conditions exist as described.in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS, cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well. If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in section D above the large system has failed. The owner or operator of any large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21. 2002 Check if the following have been done* You must indicate i h r "Yes" or "No" as to each of the following• Yes No X Pumping information was provided by the owner, occupant or Board of Health. X Were any of the system components pumped out in the last two weeks? X Has the system received normal flows in the previous two week person? X Have large volumes of water been introduced to the system recently or as part of this inspection? _X Were as built plans of the system obtained and examined? (If they were not available as N/A) X_ _ Was the facility or dwelling inspected for.signs of sewage back-up? X Was the site inspected for signs of breakout? X Were all system components, excluding the SAS. located on site? X Were the septic tank manholes uncovered, opened, and die interior of the septic tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum.? X Was he facility owner(and occupants, if different from owner) provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X Existing information. For example, Plan at the Board of Health. X Determined in the field(if any of the failure criteria related to part C is at issue, approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_ n/a-No plans on file at BOH Number of current residents 5. Does the residence have a garbage grinder(yes or no): yes Is laundry on a separate sewage system(yes or no): no If yes, separate inspection required .Laundry system inspected (yes or no): n/a Seasonal use(yes or no): nQ Water meter readings, if available (last two year's usage (gpd): :247 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL./INDUSTRIAL• Type of establishment: Design flow(based on 310 CMR 15.203):: gpd' Basis of design flow(seats/persons/sqft/etc.): Grease trap present: (yes or no)_ Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS source of information: System not piped in recent past(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: X 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/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components, date installed(if known) and source of information: Age: 4+ years Certificate of Compliance issued 1/26/98 (BOH permit# 98-56) 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: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 BUILDING SEWER_(Locate on site plan) Depth below grader_ Material of construction:--X—cast iron 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints, venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:X(locate on site plan) Depth below grade: 6„ Material of construction: X concrete metal_fiberglass_polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no): (attach a copy of certificate) Dimensions: 11.5 ft x 5 ft x 5 ft(1500 gallonl Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle: 30 in Scum thickness: 2 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to ton of tank Comments: (on pumping reconmiendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time Liquid level at outlet invert Tank and tees ally sound and functioning as intended No evidence of leakage in or out 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 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 inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert No solids in tank. 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 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 SOIL ABSORPTION SYSTEM (SAS): X_(locate on site plan; excavation not required) If SAS not located, explain why: Type: _leaching pits, number _leaching chambers, number Teaching galleries, number I beaching trenches, number, length beaching fields, number, dimensions _overflow cesspool, number. --jnno vative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils above leaching gallery appeared unsaturated No evidence of surface ponding, lush veg a ion, or other evidence of hydraulic failure was observed CESSPOOLS: none (cesspool must be pumped at time 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 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: Lune 21, 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' (Locate where public water supply enters the building) LOCATIONS ° ° A B 1 33.5 ft 27 ft ° 2 25 f t 46 f t 3 3 30 f t 52 f t o o SEPTIC 2❑ D-BOX TANK g A 3 BEDROOM DWELLING # 350 J z J O W I- 3 MIRCHELL S WAY NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 350 Mitchell's Way Hyannis Owner: Leonard Green Date of Inspection: June 21, 2002 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 122+ feet Please indicate (check) all methods used to determine high ground water elevation: Obtained from system design plans on record -If checked. date of design plan reviewed X Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators, installers-attach doctunentation) X Accessed USGS database You must describe how you established the high ground water elevation. Comparison of USGS Topography mans and surface water elevation data shows site to be over 12 feet above groundwater. Applying an adjustment factor of 4.8 feet(Index well A1W-230, zone D, May 2002 level =24.1) demonstrates that bottom of SAS is above ad-justed high groundwater 11 Co.mmO\'WEALTH OF MASSACHI;SETTS 1; ExECi TIVE OFFICE OF ENVIRONME\TAL AFF-AIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE Nt NTER STREE7. BOSTON bLA 0210E 1617) 292-550t, TRUDY COX: Secretan ARGEO PALL CELLUCCL. 1 DAVID B STRtuS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 350 Mitchells Way, HyanniUaneofOwrer 'Robert Gonella/ Argon Address of Owner: Date of lnspection:.Z—;7 02 p J Name of Inspector:(Please Print)WM. E , Robinson Sr. 1 am a DEP approved systerrl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinsoneptic Service Mailing Address: PO Box 0 9, Centerville MA Telephone Number: q;A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in-the proper function and maintenance of on-site sewage disposal systems. The system: _ asses Conditionally Passes- _ Needs Further Evaluation By the Local Approving Authority Fails 0041 Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a'design flow of,10,000 gpd or greater,the inspector and the system owner ` shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Q r r EU +� a 2000 DEPT. I" {. revised 9/2/98 Page Iof11 ti -.anted on Req•c;rd Pa.n _ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) 'rop"Address: 350 Mitchells Way, Hyannis Owner: Robert Gonella Date of Inspection: .7- -P_a p-o—fu INSPECTION SUMMARY: Check 0 B, C, of D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S STEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved oy the Board of Health, will pass. Indicate es, no, or not determined (Y. N, or NO). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 1 revised 9/2/98 Page 2of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION`(continued) Property Address: 350 Mitchells Way, Hyannis Own«: Robert Gonella Date of Inspection: q C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: )pb ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the c health, safety and the environment:' 1) TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspoot'or privy is within 50 feet of a bordering vegetate wetlandor a salt marsh. 21 YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS", FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system-,(SAS)and the SAS is within 100 feet of a surface water supply or . tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a t private water supply well, unless a well wateranalysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER revised 9/2/98 Page 3or]I' SUBSURFACE SEWAIaE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Pr Address: 350 Mitehells Way, Hyannis OwRobert Gonella Date of Inspection: D. SYSTEM FAILS: You m'aN indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LA GE SYSTEM FAILS: You mu indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offiicc of the Department for further information. V X revised 9/2/98 Page 4ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 350 Mitchells Way, Hyannis D"'"e` Robert. Gonella Date of Inspection j �C.,-2—*4 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Y.xs No < Pumping information was provided by the owner, occupant, or Board of Health. N _ None of the system components have been pumped for at least two weeks and•the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N;A. _ The facility or dwelling was inspected for signs of sewage'back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. . All system components, excluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. M _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / [15.302(3)(b)1 v _ The facility owner (and occupants,if differeru from owner)were provided with information on the proper maintEnan - f Subsurface Disposal Systems. t revised 9 2/98 Page5of11 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rroperty Address: 350 Mitchells Way, Hyannis owner: Robert Gonella Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ! Og.p.d./bedroom. Number of bedrooms Idesig): Number of bedrooms(actual): Total DESIGN flow_ " Number of current residents: . Garbage grinder(yes or no): A 0 Laundry(separate system) (yes or no):/tl & If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/—'b Water meter readings, if available (last two year's usage (gpol: aq Sump Pump (yes or no):/(✓0 Last date of occupancy:7--9—.2&z v 4 Q C/ aso w a COMMERCIAL/INDUSTRIAL: J Type of es ablishment: Design flo : cpd ( Based on 15.203) Basis of des gn flow Grease trap resent: (yes or no)_ Industrial W ste Holding Tank present: (yes or no)_ Non-sanitar waste discharged to the Title 5 system: (yes or no)_ Water mete readings, if available: Last date o occupancy: OTHER: ( as, Last date�pf occupancy: GENERAL INFORMATION PUMPING RECORDS p spurc�f information: System pumped as part of inspection: (yes or no)-Z: If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) J U revised 10/2/9.c Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 350 Mitchells Way,'i Hyannis Owner: Robert Gonella " Date of Inspection: • BUIL SEWER: (Locate i n site plan) ` Depth be low grade:_ Material f construction:_cast iron_40 PVC other(explain) Distant from private water supply well or suction line DiameteJ Comme ts: (condition of joints, venting,evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) <4 Depth below grade: Material of construction: Leoncrete_metal_Fiberglass•_Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance (Yes/No) Dimensions: �n `� Sludge depth: •��lJ" e� Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: /—off Distance from top of scum to top of outlet tee or baffle: O Distance from bottom of scum to bottom f outle r a t tee offle: How dimensions were determined: w b� ,omments: (recommendation for pumping, c dition of inlet and/outlet�es or ba les, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc'.) . FG �' .a/ �- '� l AL Al ,�✓ !r Y .. .. GREA TRAP: s - (locate o site plan) Depth belo grader `" k Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions Scum thick ess: Distance fr m top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet,tee or baffle: Date of I st pumping;, Comment :. Irecomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,. evident of leakage, etc.)- revised 9/2/98 page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 350 Mitchells Way, Hyannis owner: Robert ' Gonella Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm esent Alarm evel: Alarm in working order: Yes_ No_ Date f previous pumping: Co ents: Icon ion of inlet tee, condition of*alarm and float switches, etc.) DISTRIBUTION BOX: " (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributio is a al, evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUM)on MBER:_ (locatite plan) Pumporking order: (Yes or No) Alarmorking order(Yes or No)Comm(note ion of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `' SYSTEM INFORMATION(continued) Irop"Address: 350 Mitchells Way, Hyannis f °"rust: Robert Gonella Date of Inspection: Z SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: o. Type: leaching pits, number:_ leaching chambers, number: 3 leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number. Altemative system: Name of Technology: Comments: (note conditionof soil, signs o hd raulic failure, level of po ding, damp soilndition of vegetation, etc.) . CESSP (locate on sit plan) Number and co figuration: Depth-top of liq id to inlet invert: Depth of solids yer: )epth of scum I yer: Dimensions of c sspool: Materials of co truction: a Indication of gr undwater: inflow.Icesspool must be pumped as part of inspection) Comments: (note condi on of soil, signs of hydraulic failure, level of ponding,,condition of vegetation, etc.) :Lp ce plan)construction: gDimensions: ids:( ion of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) reVis"^ 9/2 /7v Page 9,of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "roperty Address:350 Mitchells Way, Hyannis )weer: Robert Goriella Jate of Inspection: % �I SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) V- 1 V 0 revised 9/2/9R Page 10of11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Icontinuedl ropertyAddress: 350 Mitehells Way, Hyannis - Owner: Robert Gonella Date of Inspection: NRCS Report name J Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells x. Estimated Depth to Groundwater.20Feet Please indicate all the methods used to determine High Groundwater Elevation: 0 tained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps. Checked pumping records Checked local excavators, installers Used USGS'Data Describe how you established the High Groundwater Elevation. (Must be completed) I6 '7 revised 9/2/96 Page tiorit . d - TOWN OF BARNSTABLE LOCATION SEWAGE # Fj :`VILLAGE.. �lvg,17 j1,5 ASSESSOR'S MAP& LOT ...,:INSTALLER'S NAME&PHONE NO. plj7 ZY77. ' ,:.SEPTIC TANK CAPACITY 5jD0 LEACHING FACILITY: (type. -&k/40t erJ (size) e2 ' N0.`OF BEDROOMS BUILDER OR OWNER PERMITDATE: /Iv�6I4 COMPLIANCE DATE:_ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet pri-ate Water-.Supply Well and Leaching Facility (If any wells exist on:site or within 200 feet of leaching facility) Feet Ed e.of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Arc S "ono# J o ptd J� TOWN OF BARNSTABLE LOCATION ® I'I�f C`ic.��� W 4 l e SEWAGE # VILLAGE 1a 15 ASSESSOR'S MAP & LOT S.9/- -30 INSTALLER'S NAME&PHONE NO. i�SCay� �7J-b'77C SEPTIC TANK CAPACITY ,�y�C�� LEACHING FACILITY: (type3/�/IX141 i (size), NO.OF BEDROOMS BUILDER OR OWNER ArQ ran . -A-r-QP-4r h'es PERMITDATE: i/ /� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet vEdge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �C.1 � � � � � ,�� � �, i © � . � �� •> No. > '' Fee$5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., IAA ACHUSETTS Zipplication for 33ie;pool bpgtem Congtruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address.or Lot No. 3t2&X:9:91&2X Owner's Name,Address and Tel.No. 4 2 8—5 5 6 3 350 Mitchells Way, Hyannis Argon Properties/Bob Gonella Assessor'sMaP/Parcel 4 PO Bx 772 — 844 Main St,Ostervi le 17 %... t� Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3- Lot Size sq.ft. Garbage Grinder( ng. 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 sand Nature of Repairs or Alterations(Answer when applicable) Ti _l e 5 Septic Repair consisting of a 1500g tank, D-Box and 3 stonepacked maximizers. 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 th' Bo d of Hea Signed �-� `s-�--- Date/ Application Approved by Date •-' ��- �1 ' Application Disapproved for the following reasons Permit No. Date Issued i No."i .o _ Fee 5 0.0 0 } THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MA ACHUSETTS Yes 01ppricatton for Dt.5po.5ar *pgtem Cone;tructton Vermtt Application for"a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components .Location Address or Lot No. ]k22XSSIi2X Owner's Name,Address and Tel.No. 4 2 8—5 5 6 3 350 Mitchells Way, Hyannis Argon Properties/Bob Gonella Assessor'sMap/Parcel 4p 40;7 PO BX 772 ,_­ -8`44 Main St,Ostervi le A Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address'and Tel.No. W E Robinson Septic Service PO ,Box 1089, Centerville, MA 02632 Type'of Building: Dwelling No.of Bedrooms;: ?, 3=, Lot Size sq.ft. Garbage Grinder( ng Other Type of Building t 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 sand rw Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Repair consisting of a 1500g tank, D-Box and 3 stonepacked maximizers. p Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore de%",ed-anQ4jtte sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operatl�on'until a Certifi- Cate of Compliance has been issued by th' Bo fd_of Hea Signed 4e J. ^E��`' — Date a'_—g E Application Approved by Date Z .2 gong ..0. Application Disapproved for the following reasons r Permit No. r Date Issued --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Argon Properties BARNSTABLE, MASSACHUSETTS Certtftcate of (Compliance THIS IS T&CERTIFY,that the On-site Sewage.Disposal System Constructed( )Repaired iKX )Upgraded( ) Abandoned( )by at 350 Mi tcke l l s Way, Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � dated Installer W E Robinson Septic Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date _ I ?, Inspector No.�� �- --------------------------Fee 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Argon Properties Df5po5al 6pgtem Con5tructton Vermtt Permission is hereby granted to Construct( )Repair(xX)Upgrade( )Abandon( ) System located at 350 Mitchells Way, Hyannis Installer: w E Robinson Septic Sry 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 must be completed within three years of the date of this t. Date: Approved by NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. hereby certify that the application for disposal works construction permit signed by me dated ' - �! concerning the property located at 350 Mitchells Way, Hyannis MA,_ meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED:, DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). p o 'Fu r t3 t w � a l,a