HomeMy WebLinkAbout0060 NAUTICAL ROAD - Health -' 60 4 Nauti.ca 'Road -
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No. �0 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppliCation for MispoSal 6pstpm ConstrUrtion Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon t-4 0 Complete System ❑Individual Components
Location Address or Lot No.6 2'li yNWUT CAl Owner's Nam ,Address,and T No.
07-235 9 e wroo Can - ad
Assessor's Ma arcel eel
Installe Airss,an� el.No J� -</24-�/�3 Designer's Name,Address,and Tel.No.
oSC
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 Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sigped, Date
Application Approved by ill 11, 0 Date
Application Disapproved by U Date
for the following reasons
Permit No. — �) Date Issued 0
-
/.
No.. �( r r�� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF, BARNSTABLE, MASSACHUSETTS Yes
application for jmisposal-66 strm Con-ttructionvermit
Application for a Permit to Construct( ) Repair( ) Upgrade(-)' Abandon ❑Complete System ❑Individual Components
Location Address or Lot No. -G rl Owner's Name,Address,and Tel.No.
/
Assessor's Map 9c 1 .23S -
Installer's Name,Address,and Tel.No. 0g-5;"26)-�7 3 9 Designer's Name,Address;and Tel.No.
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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.
D-scripti n 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 Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign % ,/ /l Date
Application Approved by CA Date G/— Z / Cj
`Application Disapproved by U Date
for the following reasons
Permit No. 0j Z Date Issued Viso /
r
- -----------------------------------------------
THE COMMONWEALTH OF-MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance �, ;
W&ISJO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned
at � — / � ,d has been constructed in accordance ••'""
with the provisions of Title 5 and the for Disposal S stem Construction Permit No. / - / �ated
#bedrooms 4 J /A._ Approved design flow /ij//L gpd
The issuance bf this permit shall not be construed as a guarantee that the system will function assdesigned. r
Date 7 Inspector
-------------- - --- - - -- - ---------- - ------------------------- - ---------------------------------
No. G _ / Fee-
'~ t THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) -'Abandon
( )
System located at i L 2- /� �/ y'7(' Z 6z"O e'
r
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:Construction must be completed within three years of the date of this permi.
Date L / p / PP Y Approved b J—Pf
1 ' - C
TOWN OF BARNSTABLE C C
LOCATION ����°�NF A?,� SEWAGE # �a''S`75
VILLAGE �/U�tJlS ASSESSOR'S MAP& LOT 367 l
INSTALLER'S NAME&PHONE NO. C1/ulD 566 77:-C$60
SEPTIC TANK CAPACITY 13 y��7` 41-3° D.B 0
LEACHING FACILITY: (type)�'41�C'�P �NF�f�� s (size) //,-x `�� X /0
NO. OF BEDROOMS
BUILDER OR OWNER I�DCG<Z
PERMITDATE: COMPLIANCE DATE: �3
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 leachin facility) Feet
Furnished by 0�1�
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807 - '42 3,5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "
P r-I
wM 60/64 Nautical Road
Property Address
HUD ,+
Owner Owner's Name
information is required for every Hy annis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection I „'
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Anthony Campano
use the return Name of Inspector
key.
�► � Campano Title 5 Inspections
�V Company Name
30A Elm St.
Company Address
r Pepperell MA 01463
Cityrrown State Zip Code
978433-2212 12780
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340.of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12/19/2018
Ins or's Signature Date
The m inspector
system specto shall submit a copy of this Inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I�
f
t
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is H
required for every Y annis MA 02601 12/19/2018
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
•
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ®. Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified.
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
+ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on Site?
N ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
f .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage N/A
9 ( Y 9 (gpd))�
Detail:
House has been vacant since 2016. There hasn't been any usage since that time. See attached
report from the Hyannis Water Department,.
Sump pump? ❑ Yes ® No
Last date of occupancy: not known
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats%persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection.
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: not known
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
See attached permit and as built dated 12/09/2002.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town Water
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
All exposed joints were in good condition with no evidence of leakage or venting problems.
Septic Tank locate on site plan):
p ( P )
„
Depth below grade: 8
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
The tank inlet and outlet baffles were in place and composed of PVC. The liquid level was at bottom
the baffle tees. The inlet cover was cracked and needs to be replaced. (See Attached Photos)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'Lx5'5"Wx5'
Sludge depth: 3.,
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601. 12/19/2018
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 37,.
Scum thickness None
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both the inlet and outlet baffles are in place and composed of PVC and in good condition. The tank's
inlet cover is cracked and has to be replaced. Liquid level was at the bottom of the baffle tees. The
tank is 8"below grade. (See Attached Photos)
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is Hyannis MA 02601 12/19/2018
required for every H y -
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑,fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System--Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-Box has a 16" riser which raises it to within 14"of grade. The box has equal flow to both outlet
lines. There no evidence solids carryover or leaking into or out of the box.(See attached photo)
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 6 High Cap.
Infiltrators
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of hydraulic failure, ponding or damp soil. Above the SAS is a sand and gravel yard/parking
area. (See attached photo)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityf town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 60/64 Nautical Road
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10.5' See attached soil log test#1
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: 11/15/2002
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:
See attached soil log for observation hole#1 dated 11/15/2002 they went down to 126"and no
mottling.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60/64 Nautical.Road.
Property Address
HUD
Owner Owner's Name
information is required for every Hyannis MA 02601 12/19/2018
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist.
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
y
J ` •Q ' ` ar
TOWN OF BARNSTABLE
LOCATION &0/0'P#055,�� 1j_ SEWAGE# aL,06e IS
VILLAGE ASSESSOR'S MAP &LOT I? 7— 15
_ - INSTALLER'S NAME&PHONE NO44
,
SEPTIC T K CAPACITY � ` ,2Q O `�
LEACHING FACILITY: (type)' (size)
NO.OF BEDROOMS
BUILDER OR OWNER I�4CG�z
PERMTTDATE:--JG ! 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 leachin facility) Feet
Furnished bye
Iz \ n •
f
DATE OF SOIL TEST N_ilV 15�2202—�.. .
cu.rc'TecQ FH�It4EERING sum
I SOIL TEST DONE BY
WITNESSED BY
RVATtON HOsE 1
ELEV.=_98.80 z`
PERCOLATION.
RATE. _< 2 MIN./INCH AT INGH ' '
' ty Sh 9✓s3':
DEPTH HOR11 TEXTURE GOLOR TT. OTHER
LEGEND:
0-12 Ap LOAMY SAND 10YR3/3 NO
EXISTING .SPOT ELEVATION 00„Q.
EXISTING CONTOUR --- OQ---- " .
FINAL SPOT ELEVATION i 12-40 B LOAMY SAND t0YR5/8
FINAL CONTOUR 207. C098LE5
SOIL TEST LOCATION 40-126 C COARSE SAND 2.5Y7/6
UTILITY POLE
TOWN WATER �WW
CATCH BAST ,
GG\ l i
GAS LINE C.
s Pm
CLEAN OUT
SPOOL C.P.
CESSPOOL O
x
NO WATER ENCOUNTERED.AT __12fi_- ELEV. ._
DESIGN CALCULATIONS
DESI ,�
NUMBER OF BEDROOMS 3
GARBAGE DISPOSAL UNIT --�-=
TOTAL ESTIMATED FLOW " I
( 110 GAL./8R./DI1Y X ..4_. �•) _ _ GAL/DAY
REQUIRED SEPTIC TANK CAPACITY NO) _
TANK (
1.'1w__
. ACTUAL SIZE OF SEPTIC_ .,, ;;a,.�,.�:: ��.• ,,
SOIL CLASSIFICATION ---�-- k
i DESIGN. PERCOLATION RATE �=J-- MIN.JIN `' ' 05
EFFLUENT LOADING RATE GAL,/DAY_f ,f
LEACHING AREA
e 50.
(1108)+(89=10/12) GAL./DAY
/DAY r
LEACHING CAPACITY (AREA X RATE) ' `al
t:
828.33 X 0.74
RESERVE LEACHING CAPACITY BONE GAL./.DAY
_ NOTES'
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO
TITLE 5 AND THE TOWN OF _
RULES ,AHD
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF
2. ALL COVERS TO .SANITARY UNITS SHALL BE BROUGHT TO
WITHIN 6" OF FINISHED GRADE. r ~
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL 8E
WITHSTANDING H-10 LOADING UNLESS THEY ARE. UND&A-OR WITHIN
}
FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL 8 -
10. x :.
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS,
4. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL '
FE �nnRTAaEn iN PLACE.
_ _.
5. NO OE.T€RMINA110N HAS BEEN MADE AS T6 Y
DEEDED OR ZONING REGULATIONS. OWNER / A-FOLIC 1 n .,
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AyT'ORITY 2
6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATIQN; QN'ICTt ,
IS TO CALF"DIG-SAFE" AT 1-888-3'44-7233 AT LEAST 72 .IiQURS,
PRIOR TO COMMENCING WORK ON -SITE. ,
7. CONTRACTOR IS TO VERIFY .GRADES AND ELEVATIONS-A'S Wes. f�
SITE CONDITIONS PRIOR TO COMMENCING. WORK ON SIT AON""A 11�lT1 -,
IS TO 'BE BROUGHT TO THE ATTENTION OF THE •DESIGN OG WEER kw '
IMMEDIATELY.
B. PARCEL 'IS iN FLOOD ZONE _ C- �
9. COT IS 51i0Wt�f'ON ASSESSORS lG F_ 307 AS PARCEL. niiiql
10. SANITARY TEES ARE TO BE REPLACED IN SEPTIC TANKS Ailft�, .
11. EXISTING LEACHING PITS ARE TO BE PUMPED AND_ REMOV)=1), $
12. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNNDER AN
A MINIMUM OF 5' AROUND SOIL ABSORPTION SYSTEM AND B
� ytNOf WITH SAND.AS SPECIFIED IN 310 CMR 15.255:(3). °
T.A'
No. a0o 2+ S7� e r f. a= Fee_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for ;Di,5po!gaf 6psstem Con!5truction Permit - .
Application for a Permit to Construct(. )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
(.0/tP4 Nd,C-�I�e,L wG.'/ EV1N -\w+C] AuctA v6'EC-�`E-L_1
Assessor's Map/Parcel A��t S k I al*cA;w�p Sr . H yA n.i w t s &A.A .
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�� C Gv� "itb DL1.eK4_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 4 -gallons per day. Calculated daily flow 44 c_-� gallons.
Plan Date 11/1 J&�z, Number of sheets Revision Date d
Tittle ------- �--- -. . __
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 Title 5 oVEEnv* nine tal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thislth.
Signe Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 2OoZ-3"7 5 Date Issued 12ZIlka
--- ----------- --------------------
THE COMMONWEALTR OFWASSACHUSETTS
BARNSTABLIASSACHUSETTS
Certificate of Compliance
THIS IS TO CER e O -si Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandon ( )bI� w 1�
at 6 t W�� I "\G h has been constructed in accordance
with the provisions of Title 5 and the for Di posal System Construction Permit No. �0aa-5-?r dated d 9le
Installer Designer I n
The issuance of s ermi hall not be construed as a guarantee that the s e 1 ctio as gnu/. c
Date Inspector , 2
r
HeaNh Marta Detail t= , -
Y :.� ��.vxix✓eS n �� �
..: .....,,..., as ..
�.,, .t.kL� SePtIG R 313 9 fr 4 3Y3,�'"1P
Parcel 307 235 Location b0 NAIITICAt ROAR,Nyannt5 Owner:CHASE NOktE PINANCE�LLL`�'• - - - - -
___......._..............___..._ ___._.. -.
Septic 1,12J9J2002 z�Neau Septic F .
Permit number: Pernittype:. SeleGtype Complete systern:0.' I
Issue date:.'12/912002 - Complete date.,; 1/24R003 M -
Septic tank size: 1500 Type61zie bf�SAS:ID-BOX WJ(G).HIGH CAP INFILTRATORS -
Installer FSeleck Installer Card on file Cl
IT
Innbvative AlYemative Technolo.Py type: -
I/A service type;'SeleG sardce vl 'Select IA type Y!
,.I Variance date: — .:3''Abalidon-coitlU[e�date: - - A bandon permit number E �
Repair deadilne d Repair notification date + Keyword:
. c i...
....................... ._.__.......__a..__....._.-._.__ Y
Comm nts; DUPLEX:0 BEDS TOTAL EXISTING ' �" '='1 Delete Septic i
W,i2,Inspection4 002
u r-
Number Inspection Date Inspacto -- ------^-^" - Result -
37 9/412002 !. FGrad_John P ,JOHNGRACI SEPTIC SERVICE'T -IF/R(FaiURepalred)
.'LThe following conditions)are occurring: -
,_)discharge or ponding of effluent to the:surface of the ground,
.pumping more than4 times during the last year NOT due to dogged or bbstricted pipe
i`..)backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool
static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool €
"ii J any portion of the SAS,cesspool,or privy below high groundwater elevation ' -
;_;)any portion of the cesspool within a Zone l to a public welt
u any portion of a cesspool within 50 feet.of a private water supply well with no acceptable water quality analysis
i Received Date Comments
!'
;, Duplex-unoccupied v Qelete lnepecUon .�
Save Septic Changan �; Retum id Lpakup ;� !„1
r
f� Type here 10 search � .r �
- Yf' -� f��' U V1�1 Cam' 1 -(-1-1 w
Date: 12/17/2018 q-7 8,qq 57- r_, ��'tdad' ding Hist01'� Page l of t
Customer# 6047764 - co,j Qm e
Premise#604776 " C0 t' )
Service:Water-Regular Metered ���h-ey k n
METER READING _ TRANSACTION INFO
Read Date Sectuenoe Meter# Face Sort # Read Code Reading Consumift Skin Count Type Code Status Bill Period Trans Date
091102018 01 68244396 0 30021660 1 148.00 0.00 0 REG A R 201803 09/19/2018
0610412018 01 68244396 0 30021660 1 148.00 0.00 '0 REG A R 201802 06/10/2018
03/06/2018 01 68244396 0 30021660 1 148.00 0.00 0 REG A R 201801 03/12/2018
12/04/2017 01 68244396 0 30021660 1 148.00 0.00 0 REG A R 201704 12/18/2017
091052017 01 68244396 0 30021660 1 148.00 0.00 0 REG A R 201703 09/11/2017
06/05/2017 01 68244396 0 30021660 1 148.00 0-00 0 REG A R 201702 06/182017
031072017 01 68244396 0 30021660 1 148.00 0.00 0 , REG A R 201701 03/202017
121062016` _. 01 68244396 0 30021660 1 148.00 24.00 0 REG A R 201604 12/15/2016
09/06/2016 r�� 01 68244396 0 30021660 •1 101.00 30.00 0 REG A R 201602 06/162016
06/06/2016
03/0720.- 01 68244396 0 30021660 1 71.00 _ 16.00 0 REG A R 201601 03/212016
12/07/2015 01,68244396 0 30021660 1. 55.00 29.00 0 REG A R 201504 12/162015
09/08/2015 01 68244396 0 30021660 .1, 26.00 17.00 0 REG A R 201563 09/16/2015
06/082015 01 68244396 0 30021660 1 9.00 9.00 0 REG A R 201502 06/182015
0324/2015 01 61699511 0 30021660 1; 2.123.00 0.00 0 REG A O 201502 03/242015
03242015 01 68244396 0 30021660 1 0.00 0.00 0 REG A S 201502 03/24/2015
03/04/2015 01 61699511 0 30021660 V" 1; 2,123.00 0.00 0 REG A R 201501' 03/17/2015
12/10/2014 01 61699511 0 30021660 1 2.123.00 0.00 0 REG A R 201404 12/172014
0924/2014 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201403 09/302014
06/132014 01 61699511 0 30021660 1 2,123.00 +0.00 0 REG A R 201402 06/212014
03/18/2014 01 61699511 0 30021660 1 2.123.00 0.00 0 REG A R 201401 03/242014
-12/132013 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201304 12/18/2013
09/162013 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201303 09/232013
06/14/2013 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201302 06/232013
03/15/2013 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201301 03/202013
12/13/2012 01 61699511 0 30021660 f 2,123.00 0.00 0 REG A R 201204 12/192012
09/14/2012 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201203 09/192012
06/12/2012 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201202 06/212012
03/20/2012 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201201 03222012
12/142011 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201104 1221/2011
09/15/2011 01 61699511 0,30021660 1. 2,123.00 0:00 0 . REG A R 201103 09212011
06/15/2011 01 61699511 0 30021660 1 2,123.00 0.00 0 REG A R 201102 06/22/2011
03/14/2011 01 61699511 0 30021660 1 2,123.00 1.00 0 REG ' A R 201101 03/232011
12/162010 01 61699511 0 30021660 1 2,122.00 4.00 0 REG A R 201004 1226/2010
09292010 01 61699511 0 30021660 1 2.118.00 _ 17.00 0 REG A R 201003 10/052010
Dare: 12/17/2018 Meter Reading-IHisto Page 2 of 2
Customer## 604776-1
Prerinlse#694776
Sereiuce.Water-Regular Metered
METER READING. ._ TRANSACTION INFO
Read Date Seauenoe# Meter* Face Sort # �efid Code Read Consumption SWw Count Tye Code Status Bill Period Trans Date
OW162010 01 61699511 0 300121660 1 2,101.00 26.00 0 REG A R 201002 O6/242010
03/162010 01 61699511 0 30021660 1 2,075.00 29.00 0 REG A R 201001 03/24/2010
12/17/2009 01 61699511 0 30021660 1 2,046.00 40.00 0 REG A R 200904 12282009
09/172009 01 61699511 0 30021660 1 2,006.00 41.00 0 REG A R 200903 09/24/2009
06/162009 01 61699511 0 30021660 1 1.965.00 40.00 0 REG A R 200902 06292009
03118/2099 01 61699511 0 30021660 1 1,925.00 41.00 0 REG A R 200901 03/182009
12/182008 01 61699511 0 30021660 1 1,884.00 56.00 0 REG A R 200804 12/18)2008
09/172008 01 61699511 0 30021660 1 1,828.00 80.00 0 REG A R 200803 09/17/2008
06116UM 01 61699511 0 30021660 1 1,748.00 50.00 0 REG A R 200802 06/162008
03✓172008 01 61699511 0 30021660 1 1,698.00 45.00 0 REG A R 200801 03/172008
12/192007 01 61699511 0 30021660 1 1,653.00 56.00 0 REG A R 200704 12/19/2007
091192007 01 61699511 0 30021660 1 1,597.00 63.00 0 REG A R 200703 09/19/2007
0620/2007 01 61699511 0 30021660 1 1,534.00 50.00 0 REG A R 200702 06/20/2007
03/192007 01 61699511 0 30021660 1 1,484.00 45.00 0 REG A R 200701 03/192007
12/182006 01 61699511 0 30021660 1 1,439.00 53.00 0 REG A R 200604 12/182005
09/19/2006 01 61699511 0 30021660 1 1,386.00 56.00 0 REG A R 206603 09/192006
06/152006 01 61699511 0 30021660 1 1,330.00 74.00 0 REG A R 200602 06/152006
03232006 01 61699511 0 30021660 1 1,256.00 0.00 0 REG A R 200601 03232006
12/162005 01 61699511 0 30021660 1 1,138.00 0.00 0 REG A R 200504 12/162005
` —._._...— 0k�2403f�Pia 343- —053253---
07-16-2009 & 03024P
DIEED RESTRICTION
WHEREAS, 44EyN =9' a t✓'EIa of
( a name)
Is the owner of bo- Ala ►1 U located
MA(hereinafter referred to as a afli-5 ✓—&X
and bpjng shown on a plan entitled"Subdivislon a f d in �
Kti S MA, Property of..J i1 P. n
et al, Lot 8 duly recorded In Barnstable County Registry
of
%Cho Deeds in Plan Book Page . °
n..
Dr on Land Court Plan Number
x WHEREAS, kl Amii. �;Vgr rr. as the owner of said lot has
O (aecrtes'a nama . '
-4 agreed with the Town of Barnstable Board of Health to a restriction as to the
-� number of bedrooms which can be included in any home built on said tot as a '
4, pre-condition to obtaining a disposal works construction permit fn compliance
a► with 310 CMR 15.000 State Environmental Code,Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS,the Town of Barnstable Board of Health, as a pre-condihonto
granting a disposal works construction permit for a septic system In compliance
with 310 CMR 15.200. State Environmental Code,Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing
the Issuance of a building permit for the construction of a single family home on
this property, is requiring that the agreement for the restriction on the number of
bedrooms in.any*house constructed on the lot be put on record with the.'
Barnstable County Registry of Dees qy recording this document,
Bk 24036 Pg 344 #53253
NOW,THEREFORE, Hk A4A Z- (9Liy—F,94.does hereby place the
- (ovrt�r's ram)
following restriction on his above-referenced land_ In accordance with his
d iatbe.Tm a at .
run with the land and be binding upon aN;sucoessors in tide:
1. G4 )Uta ZL ►t1:5 may have constructed
(eddme).
u on the lot a house oontainr no more than (J)bedrooms.
�'VMk j• 041 agrees that this shall be-permanent deed
. (arners name)
restriction affecting located on - MA, and, .
being shown on the plan recorded In Plan Book , Paged 1
Or-on Land-Court Plan
For title of see the following deed: Book . , Page
. Or Land Court Certificate of Title Number
Executed as a seated instrument day of
P�crnG. :
Owner's signature
Owner's signatures
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
Barnstable ss
60a 2009 .20_
Then perionaUy fU the above-named
known to me to be the person who executed the foregoing Instrument and_,.,.�_
r
acknowled Blass Drivers licence r.�'���F K»III a, ..
the same to be h�L`'12 free act and d d, ......
�
lit 40 a
` 'Notary►',-..> 4 •!�
Public. .. ••'
My c iOd ,tAvR ,`�/►r ee+rv ,•`
tss�CF�
d=* B STAM REGISTRY OF DEEDS
n
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f
oFTME Ta,, Town of Barnstable
Regulatory Services
9 MASS. Ricar d Scali,Director
1639• �0
Public Health Division
Thomas.McKean, Director
200 Main Street,_Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
November 3, 2016
Melissa Bollin, et. Al
64 Nautical Road
Hyannis, Ma 02601
EMERGENCY CONDEMNATION AND ORDER TO
VACATE
In accordance with M.G.L. c.l 1.1, sec. 127A and 12713,,105 CMR 400.000: State Sanitary
Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary t
Code, Chapter II: Minimum Standards of Fitness for Humans. Timothy B. O'Connell, R.S.,
Health Inspector for the Town of Barnstable on November 3, 2016 conducted an investigation
of a dwelling unit located at 64 Nautical Road, Hyannis, MA. The owner's name of this,
dwelling unit is Chase Home Finance LLG. The tenants) name(s) are Melissa Bollin, et.Al
Based on the results of that investigation,the Barnstable Health Department finds
that the dwelling is.unfit for human habitation.. Pursuant to M.G.L. c. 127B and
105 CMR 410.831 (D), (E)the Health Department further finds that the conditions "
within the dwelling are such that the danger to the life or health of the occupants of
the subject dwelling is.so immediate that no delay may be permitted in making this
finding.-Conditions found within the dwelling, which give rise to the emergency
finding of unfitness and determination of immediate danger, include: ;
G
410. 750: Conditions Deemed to Endanger or Impair Health or Safety
410.750 (B) -Failure to provide_heat.
410.750 (C)—Shoutod and/or failure to restore electricity, gas or water
QAOrder LettersTondemnations\60 nautical 11-3-16
410.750 (H)—Failure to comply with security requirements of 105 CMR 410.480
(D)
410.750 (P)—Garbage and filth throughout in back yard.
Based upon these findings any.and all occupants are hereby ordered to vacate
within (24) twenty-four hours and the landlord/owner is ordered to secure the
subject dwelling within 48 hours of receipt of this order.
If any person refuses to leave a dwelling or portion thereof, which was ordered
vacated they may be forcibly removed`by the local Board of Health (Massachusetts
General Laws C. 127B), or by local police'authorities at request of the Board of
Health.
Furthermore, anyone who fails,to comply with any order of the board of health may
be subject to fines ranging from $104500. Each day's failure to comply with an
order shall constitute a separate violation.
You may request a hearing before the Board of Health if written petition requesting
same is received within forty-eight(48)hours after the date the order is served.
Once vacated this unit may not be occupied until heat are restored to this unit and
garbage and filth cleaned within home and back yard. {
Note: This is an important legal document. It may affect your rights.
� y
PER ORDER OF THE BOARD OF HEALTH.
' t
McKean, CHOIRS
Director of Public Health
Town of Barnstable '
Cc: Officer Gallant, Town of Barnstable Police;Department.
Robin Anderson, Town of Barnstable Zoning Office
Chase Home Finance LLC
Q:\Order Letters\Condemnations\60 nautical 11-3116
_r .,_.-....�,....<-y'tr- .y- -.�.. .Y..:-.. .;. ;.',.+..e rti_^Y.• •.T:�rysxa^.,..e � w -,.'Vch.•-ti.i'.da-.1"'Y'^-r
TOWN OF BARNSTABLE BAR-W 5938
Ordinance 'or_ Regulation
WARNING NOTI&k-'�.
Name of Offender/Manager �POMA T
Address of Offender MV/MB Reg.#
Village/State/Zip , ,r►a, f Ill j
. / P
/pm o
Business Name d d am ,: on �//_7/20G
Business Address
Signature of Enforcing Officer
Village/State/Zip
Location of Offense 64 } > . 4. C! f- ,,s ��r a fp
-�• (� /' I Enforcing/tept/Division
Offense It Nam+ # �1 )o41'r hf' / / s i 3y3—
} i
Facts f! ..�ira a t ,f.A f)or S�n� l P+cr�F/ E�(a ✓+ J.'-,'A Lome 0 A L
- P/-, 6, 5" r I"p 6" '9 1�L4 P o r lkd- `0/,1 A'(4 � �P�f
This will serve only as a warning. At this time no/legal action has been taken.'
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN-,OF BARNSTABLE BAR-W 5938
Ordinance .6r,Regulation
WARNING NOTICE '
.Name of' Offender/Manager 00 V r4 /rq
Address of Offender LL, MV/MB Reg.#
Village/State/Zip f VV 0 1 --
Business Name /pm, on f 2 O{j
Business Address
Si4hature ,of Enforcing Officer
Village/State/Zip
Location of Offense I(" Ei
Enfbrcing,Dept/Division
Offenses
Facts j^j %if,
This will serve only as a warbirij. . At this time no/legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Edu"cation efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will -result in
appropriate legal action by the tbuffi.
WHITE-OFFENDER CANARY-OR,DJRE G.-PROG. PINK-ENFORCING OFFICER -GOLD ENFORCING DEPT.
oF1NE r Town of Barnstable
� o
' Regulatory Services
BARNS�e MASS. Richard Scali,Director
tj i639• �0
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Certified Mail: 7014 1200 0001 0358 4374
November 3,2016
Chase Home Finance LLC
800 Brooksedge Boulevard.
Westerville, OH 43081
Finding of Unfitness for Human Habitation and
Determination of Immediate Danger
In accordance with M.G.L. c.111, sec. 127A and 127B, 105 CMR 400.000: State
Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR
410.000: State SanitaryCode, Chapter II: Minimum Standards of Fitness for
Humans. Timothy B. O'Connell, R.S.;Health Inspector for the Town'of
Barnstable on November 3, 2016 conducted an investigation of a dwelling unit
located at 60 Nautical Road, Hyannis, MA. The owner's name of this dwelling
C unit is Bank of America. The tenant(s)'riame(s)are Kaileen Crane, Richard
Mojica, Clayton Garcia, Krystal Stendzis, Danmelle Gincauskis and Josh
McCarthy, et. Al.
Based on the results of that investigation, the Barnstable Health Department finds
that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and
105 CMR 410.831 (D),(E)the Health Department further finds that the conditions
within the dwelling are such that the danger to the life or health of the occupants of
the subject dwelling is so immediate that no delay may be permitted in making this,
finding. Conditions found within the.dwelling,which give rise to the emergency
finding of unfitness and.determination of immediate danger, include:
410. 750: Conditions,Deemed to Endanger or Impair Health or Safety
410.750 (B)!- Failure to provide heat.
410.750 ( C )=Shoutoff and/or failure to restore electricity, gas or water
410.750 (F)=Failure to provide and maintain a sewage disposal system in
operable condition.
410.750 (G) - Failure to provide adequate exits from said unit as determined by
708CMR 3400.5.1 of Massachusetts State Building Code. (Basement rooms and
kitchen sliding glass door)
Q:\Order Letters\Condemnations\60 nautical way
410.750 (H)—Failure to comply with security requirements of 105 CMR 410.480
(D)
410.750 (I)—Failure to complyrwith any provision of 105 CMR 410.600, or
410.602 which results in any accumulation of garbage, rubbish, filth or other
causes of sickness which may provide a food source or harborage for rodents,
insects or other pests
i
410.750 (N)—Smoke Detectors and CO detectors were not present with in home.
410.750 (P)—Garbage and filth throughout home and back yard.
Based upon these findings any and all occupants are hereby ordered to vacate
within(24)twenty-four hours and the landlord/owner is ordered to secure the
subject dwelling within 48 hours of receipt of this order. If any person refuses to
leave a dwelling or portion thereof,which was ordered vacated they may be
forcibly removed by the local Board of Health(Massachusetts General Laws C.
127B), or by local police'authorities at request of the Board of Health.
You may request a hearing-before the Board of Health if written petition requesting
same is received within forty-eight(48) hours after the date the order is served.
Furthermore, anyone who fails;to comply with any order of the board of health may
be subject to fines ranging from$104500. Each day's failure to comply with an
order shall constitute a separate violation.
Once vacated this unit may.not be occupied until heat are restored to this unit and
garbage and filth cleaned within home and:back yard.
Note: This is an important legal document. It may affect your rights.
PER ORDER OF TH OARD OF HEALTH
IcKean, CHOIR
Director of Public Health
Town of Barnstable
Cc: Sgt. Sweeny, Town of Barnstable Police Department.
Robin Anderson, Town of Barnstable Zoning Office
Officer Gallant, Town of Barnstable Police Department.
Occupants:
Josh McCarthy, et. Al
Kaileen Crane
Richard Mojica
Clayton Garcia
Krystal Stendzis
Dannielle Gincauskis
Q:\Order Letters\Condemnations\60 nautical way
1
Op THE r Town of Barnstable
Regulatory Services
* BARNISTABLE,
9 Mass. g Ricard-Scali,.Director
039.
Public Health Division
Thomas McKean, Director
200 Main-Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304 .
November 3, 2016
Josh McCarthy, et. Al
Kaileen Crane
Richard Mojica
Clayton Garcia
Krystal Stendzis
Dannielle Gincauskis
60 Nautical Road
Hyannis, Ma 02601
EMERGENCY CONDEMNATION AND ORDER TO ,
VACATE -
L
In accordance with M.G.L. c.1 l 1,"sec. 127A and 127B, 105 CMR 400.000: State Sanitary
Code, Chapter I: General-Administrative Procedures and 105 CMR 410.000: State Sanitary
Code, Chapter II: Minimum Standards-of Fitness for Humans. Timothy B. O'Connell,R.S.,
Health Inspector for the Town of Barnstable.on November 3, 2016 conducted an investigation
of a dwelling unit located at 60 Nautical Road, Hyannis, MA. The owner's name of this
dwelling unit is Chase Home Finance LLC. The tenant(s) name(s) are Kaileen Crane, Richard
Mojica, Clayton Garcia, Krystal Stendzis, Dannielle Gincauskis and Josh McCarthy, et. Al
Based on the results of that investigation, the Barnstable Health Department finds
that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and
105 CMR 410.831 (D);(E)the Health Department further finds that the conditions
within the dwelling are such that the danger to the life or health of the occupants of .
the subject dwelling is so immediate that no delay may be permitted in making this
finding.
Q:\Order Letters\Condemnations\60 nautical 11-3-16 x
I
Conditions found within the dwelling, which give rise to the emergency finding of
unfitness and determination of immediate danger, include:
410. 750: Conditions Deemed to Endanger or Impair Health or Safety
410.750 (B) - Failure to provide heat.
410.750 ( C )—Shoutoff and/or failure'to restore electricity, gas or water
410.750 (F)—Failure to provide and maintain a sewage disposal system in
operable condition.
410.750 (G) -Failure to provide adequate exits from said unit as determined by
708CMR 3400.5.1 of Massachusetts State Building Code. (Basement rooms and
kitchen sliding glass door)
410.750 (H)—Failure to comply with security requirements of 105 CMR 410.480
(D)
410.750 (1)—Failure to comply with any provision of 105 CMR 410.600, or
410.602 which results in any accumulation of garbage, rubbish, filth or other
causes of sickness which may provide a food source or harborage for rodents,
insects or other pests
410.750 (N)— Smoke Detectors and CO detectors were not present with in home.
410,750 (P)—Garbage and•filth throughout home and back yard.
Based upon these findings any and all occupants are hereby ordered to vacate
within (24) twenty-four hours and the landlord/owner is ordered to secure the
subject dwelling within 48 hours of receipt of this order.
If any person refuses to-leave a dwelling or portion thereof, which was ordered
vacated they may be forcibly removed by the local Board of Health(Massachusetts'
General Laws C 127B), or by local police authorities at request of the Board of
Health.
Furthermore, anyone who fails to comply with any order of the board of health may
be subject to fines ranging from$104500. Each day's failure to comply with an
order shall constitute a separate violation.
You may request a hearing before the Board of Health if written petition requesting
same is received within forty-eight(48)hours after the date the order is served.
Once vacated this unit may not be occupied until heat are restored to this unit and
garbage and filth cleaned within home and back yard.
Note: This is an important legal document. It may affect your rights.
QAOrder Letters\Condemnations\60 nautical 11-3-16
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, CHOIRS
Director of Public Health
Town of Barnstable
Cc: Officer Gallant, Town of Barnstable Police Department.
Robin Anderson, Town of Barnstable Zoning Office
Chase Home Finance LLC
Q:\Order Letters\Condemnations\60 nautical 11-3-16
sl'
RECEIVED
OCT 15 2002
COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE
HEALTH DEPT.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F DEVARTMENT OF ENVIRONMENTAL PROTECTION
733
FAILED INSPECTION
r TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEN
SUBSURFACE:SEWAGE DISPOSAL SYSTEM FORM
t ° PART A �o 0L'J'
CERTIFICATION
9 -
D� 2
Property Address: 60/64 NAUTICAL W�,HYANNIS,MA 02601
Owner's Name: KEVIN V016ELI
Owner's Address: 19 CAMP ST HYANNIS,MA 02601 l�
Date of Inspection: 9/4/02
Name of Inspector: (Please rint) 'r:J OHN GRACI1.P S- t
Company Name: EPTIC INSPECTIO NS (�
Cat
Mailing Address: �l' ;PfO,. 90X'4119 TEAT ICKET,MA.02536
Telephone Number: 508-564-680'FAX 508-564-7270
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address ar�d 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�mainterance 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 `1
_ Conditionally P s
_ Needs Further aluation by the Local Approving Authority
X Fails
Inspector's Signature ;s Date: 9/4/02
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti . 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-fhe buyer, if applicable,and the approving authority.
.Notes and Comments �� +• �°�'
SYSTEM FAILED TITLE V INSPECTION. ONE LEACH PIT HAS BEEN FULL;THE OTHER WAS FULL AT TIME OF
INSPECTION. SYSTEM NEEDS N%EW;"i EES
****This report only describes conditons at the time of inspection and under the conditions of use at that time. This
inspection does not address how the-systc!a will perform in the future under the same or different conditions of Ilse.
•C1 '
Page 2 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60/64 NAUTICAL WAY HYANNIS,MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02 j
Inspection Summary: Check 'A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information`which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure'criteria not evaluated are indicated below.
Comments: `
SYSTEM FAILED TITLE V INSPECTION.ONE LEACH PIT HAS BEEN FULL;THE OTHER WAS FULL AT
TIME OF INSPECTION.SYSTEM NEEDS NEW TEES.
B. System Conditionally Passes:
_ One or more system components as d6scr"ibed in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement,;or,repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined,(Y,N,ND)!in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 year 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: n/a
n/a Observation of sewage backup or bleak out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled orrunev : ,distribution box. System'will pass inspection if(with approval of Board of
Health):
_ broken p.ipe(s)are replaced
W -.t_, v"
_ 0 truction,.is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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 ,
u.
ND explain: n/a `a, .
`r
- �M l r -
Page 3 of 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 60/64 NAUTICAL WAYMYANNIS,MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
C. Further Evaluation is Requ e 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
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
:4 4�
Public Water Supplier,if an determines that the
f Health and Pub Y)
2. System will fail unless the Board o ( PP
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic'tank;wand soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a-surface ater'supply..
_ The system has a septic,tank and SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within'50.feet of a private water supply well.
_ The system has a septic tank and SAS'and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to"ate`rmine distance n/a
"This system passes if the weWl vater 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.
{aSs a
3. Other: `
n/a
._ +A
1 4!r';� k• Z
Page 4 of I 1
OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
" PART A
CERTIFICATION(continued)
Property Address: 60/64 NAUTICAL WAY HYANNIS,MA.:02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each-of the following for alLinspections:
Yes No
X _ Backup of sewage into`facility er system component due to overloaded)r 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'distiibution 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 volun.:: iS less than ''/z 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 1UNE 2001 BY OWN a-R.
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 cesspodl,dr 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 eet 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 ebliform'bacteria and volatile organic comdounds 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.J
X _ (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: r,
To be considered a large system fhe,system must serve a facility with a design. Ilow of 10,000 gpd to 15,000 gpd.
You must indicate either`,`yes"or"no"to each of the following:
(The following criteria apply toy large systems,in addition to the criteria above)
yes no
X the system is within 400.feef of a surfer e drinking water supply
_ X the system is within 200 feet of a,tributary to a surface drinking water s%ply
X the system.is located in a mtrog n.5i nsitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water suppy •v:%ell
If you have answered."yes'r to any question in.Section E the system,is considered a significant threat,or answered
"yes" in Section D above the large cyst ni I... failed.The owner or OVI-110t-0f ni,;Y Ii,rge syslem Considered a significnilt Threat
under Section E or failed under Section D shall upgrade the-system in accordance wish 310 CMIt 15.304. The system owner
<should contact the appropriate regional office of the Department. ; ,4
' 3 4,
Page 5 of I I .
OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
5 PART B
CHECKLIST
Property Address: 60/6 4 NAUTICAL WAY HYANNIS, MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
Check if the following have been,done. You'must indicate"yes" or"no" as to each of the following:
Yes No
X _ Pumping information was"provided by the owner,occupant,or Board of Health
� s•
X Were any of the system cornpI orients pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period?
_ 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 note as N/A)
- : y
i1.
X _ Was the facility or dwellling inspected for signs of sewage back up?
X _ Was the site inspected fo'r signs of break out'?
X _ Were all system components,excluding 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
baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
F ,
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
x
The size and location of the So�I Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a`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)] ,
��, �In 'i• -
Ft
Page 6 of 11
OFFICIAL INSP,ECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 60/64 NAUTICAL WAY HYANNIS,MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
FLOVN CONDITIONS
RESIDENTIAL '! `6,
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 8
Does residence have a garbage grinder(yes or`no): NO
Is laundry on a separate sewage system(yes or,no): NO [if yes separate inspection required]
Laundry system inspected(yes,or no):"NO, ;F
Seasonal use: (yes or no): NO ,z
Water meter readings, if available.(last;2 years usage(gpd))jj/a.r ,� ��5� 0,�
Sump pump(yes or no): NO , v t�
Last date of occupancy:n/a
2/�
COMMERCIAL/INDUSTRIAL UZ 9 2_M/ 300
Type of establishment: n/a
Design flow(based on 310 CM.Ril'$203):%n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO '.
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the'Title'5 system(yes or no): NO
Water meter readings, if available T I�,., ,
Last date of occupancy/use: n/a
OTHER(describe): n/a : P
GENERAL INFORMATION
Pumping Records
Source of information:JUNE 20011 BY OWNER
Was system pumped as part ofthetipspection".(yes or no): NO
If yes,volume pumped: n/agallons How was,quantity pumped determined?n/a
Reason for pumping: n/a a yi
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool €
_Overflow cesspool Imo ' y
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the OEP approval
Other(describe): n/a
Approximate age of all components date installed(if known)and source of information:
1975 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
; i
Page 7 of
.3u
I,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I.
Property Address: 60/64 NAUTICAL WAY.HYANNIS,MA 02661
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02 a.
BUILDING SEWER(locate on sitep plan)
Depth below grade: 12"
Materials of construction:_cast iron,X40 PVC_other(explain): n/a
Distance from private water supply.well or-suction line: n/a
Comments(on condition of joints;:venting,,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 6"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age c611ftrmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5'6" W 5' 8""
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 4" •'.
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined: MEASURED
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 IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.SYSTEM NEEDS NEW TEES.
GREASE TRAP:_(locate on;site,plan)
Depth below grade: n/a
Material of construction:_concrete`metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a "
Scum thickness: n/a
Distance from top of scum to top of'outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle:. n/a
Date of last pumping: n/a '
Comments(on pumping recommendatiyn.s, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc;):::.
n/a
Page 8 of I 1
OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60/64 NAUTICAL WAY HYANNIS,MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a '
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present resent must be opened)(locate on site plan)
e
Depth of liquid level above outlet invert n/a„
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into.
-7
or out of box,etc.): r-
n/a ,
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):'NO _
Alarms in working order(yes or no):NO '
Comments(note condition of pump chamber,condition of pumps,and appurtenances,etc.):
n/a ;
c
Vt
•Page 9 of 11
OFFICIAL INSPECT ION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60/64 NAUTICAL WAY HYANNIS, MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type {
1000 GAL 6' X 6' leaching pits, number: 2
n/a ' leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a ieaching trenches, number, length: n/a
n/a eaching fields, number: n/a
n/a !_verflow cesspool, number: n/a
n/a •';nnovative/alternative system
:Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,daa►l;soil,condition of vegetation,etc.):
LEACH PIT#1 HAS BEEN FULL.LEACH PIT#2 WAS FULL AT TIME OF INSPECTION.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:n/a r;
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool 'n/a t
Materials of construction: n/a
Indication of groundwater inflow,{yes of no : NO
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)... a
Materials of construction: n/a
Dimensions: n/a ,
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,coalition of vegetation,etc.):
n/a
}M1
f
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60/64 NAUTICAL WAY`HYANNIS, MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
SKETCH OF SEWAGE DISPOSAL;SYSTE'M
Provide a sketch of the sewage disposal system including ties to at least two permanera reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
13
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2 ,
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1313 u�
P�C 32�
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-Page 11 of 1 I
pit
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60/64 NAUTICAL'WAY HYANNIS,MA 02601
Owner: KEVIN VOIGELI
Date of Inspection: 9/4/02
SITE EXAM
_Slope
_Surface water 3' '
_Check cellar `#'+
Shallow wells
Estimated depth to ground water 10+.feet of
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,-installers-(attach documentation)
NO Accessed USGS database explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
l
t
5
TOWN OF BARNSTABLE C' Cap
LOCATION &/ 9L7-_f_1.1L 40 SEWAGE # 4Da 'SKIS
VILLAGE ASSESSOR'S MAP & LOT 367 _J
INSTALLER'S NAME&PHONE NO. Al6 C41UCO 5 Og 775- 6�
SEPTIC TANK CAPACITY 1
LEACHING FACILITY: (type)"� �Ns (size)
NO. OF BEDROOMS
BUILDER OR OWNER I/4CGF�
PERMTTDATE: 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 � �
/
/
C r
W /
cnS W q, G
N No. QDo Z— S73 ?-. ., Fee
t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +�
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Miopaal &p.5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0 Complete System 0 Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
(-,0/4P4 tva,c.att~p1_ w4 X�ylM AwO Auctn. ve
Assessor'sMap/Parcel y 10) C-4 v o Sr . WYAovevis r_..A .
. i
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
O A 4S
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 4 l0 3 gallons per day. Calculated daily flow 44 U gallons.
Plan Date 11/1!762 Number of sheets Revision Date a d'X
Title ^fir
Size of Septic Tank /gel Type of S.A.S. r
Description of Soil r
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 Title 5 of the Env' ume tal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this o ealth.
Signe Date
Application Approved by Date U"''-
Application Disapproved for the following reasons
Permit No. 2002-, �5— Date Issued Pl
r
---------------------------------------
'o4K)6't— 5.75' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
%
ZIppiication for ]igpool *pgtem Con!aruction Permit
- Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No.- Owner's Name,Address and Tel.No.
(.ram/b4 Nacaic�,L. we. 4C—vrN AwD A,ucin. voEb�t_j
Assessor's Map/Parcel nNN'S ^ 'y �S tot a 4o—,n Sr . H yA Nw 1 s, "A
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures "-/ w
Design Flow 4 6 gallons per day. Calculated daily flow 44 v gallons.
Plan Date / v A,2 (' Number of sheets J Revision Date / 5 0
Title ' 1 ,'.:
Size of Septic Tank; kM9 Type of S.A.S.
Description of Soili�
r
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: r $
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 Env' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B`o�ra o Health.
Signed �V -Date..
Application Approved by �_ `- �' Date A A '
Application Disapproved for the following reasons
Permit No. 2002-5-7 5 �� --T Date Issued
THE COMMONWEALTH OFAASSACHUSETTS
BARNSTABL E., � ASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTI that-the On-site Se ,,age Disposal System Constructed ( )Repaired ( )Upgraded( )
Abandone ( )b '�' l=?`t ��
at (Y 6 tom- wo p .,{ has been constructed in accordance
with the provisions of Title 5 and the for Di posal System Construction Permit No. 20oa-S7 3i dated
Installer Designer
/
A AA
The issuance of is permi hall not be construed as a guarantee that the s s e� 'll unctio as dds gned/
Date J a C
Inspector 4
. _ _
No.�:2(j()2 —J_?S Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
33igpogar *pgtem Congtructiort Permit
Permission is hereby gra ted to Construct( )Repair( )Upgrade( )Abandon( )
System located at bd 6 A). In/0 c-4 i 4A,i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. c
Date:_ a 1 d Approved by Aywl; 4•
f ..
Commonwealth of Massachusetts
AL
Executive Office of. Environmental Affpirs
johnlGrad
A�PF, �DFle V Septic Inspector
Department of r r P.O ox 211
E verenntenta (Protection �� Teatt �; i�IA o253G
M UUW F.Weld ) 564 6813
Goe MW , / .
Trudy Coxe . .
t3ec ,,,Y.ECEA
®'4 DeAd B. Struhs
A C rnmipionor
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ( ,
Property Address: -ULy \ \( � Ilk - rest b� qr.
Date of Inspection: (If different)
Name of Inspector: ��lo�ollo
Company. Name, Address and Telephone.Number:
CERTIFICATION STATEMENT
I.certify that I have.personally inspected the sewage disposal,system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on Amy training and experience m'the proper function and
maintenance of on-site sewage disposal systems. The system: '
�s -
_. Conditionally Passes
Needs Further Evaluation:By.the local Approving Authority i
Fails ;
Inspector's Signature: Date. Q
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this°
inspection. If.the system is a shared system or has'a design flo" of 10,000 gpd or,greater, the inspector and the`system owner shall submit
the report to the appropriate regional office of the'Departmeni of Environmental Protection..:
The original should be sent to ine s\siem owner and copie> sell'. to the bu�.er, if applicable and the appro,ing authority.
INSPECTION SUMMARY: .
Che A, B C, or D.
AJ SYSTEM PASSES: "
I have any information which indicates that the system violates any of the failure criteria as defined to 310 qMR 15.303.
Any failure criteria not`evaluated are indicated below:
BJ SYSTEM CONDITIONALLY.PASSES:
One or more system'components need to be replaced or repaired.- The system, upon completion of the replacement or repair,
- passes inspection.
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, cracked, structurally unsound, shows substantial infiltration orexfiltration;-or tank failure is
imminent. The system will pass inspection if the'existing�septictank is'replaced with=a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winbr Street • Boston,M osseehusetts 02108 • FAX(1i17)UG-1049 a TeWphon•(817)2924800
Printed on RwMed Papa
y
6
SUBSURFACE SEWAGE DISPOSAL SYEM ST INSPECTION FORM
PART AJ.
CERTIFICATION (continued)
Property Address: r
Owner: '
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued) `
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) 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 A
distribution box )s,leyelled 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 hoard of Health:in order to determine if the system )s failing to prptect the
d.
public health, safety and the environment. '
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE'SYSTEM�IS NOT.FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND.THE ENVIRONMENT:
fit
Cesspool or privy is within 50 feet of a surface water .,
Cesspool or privy is �•ithin 50 feet of a bordering vegetated wetland or a.salt marsh.
ESS THE BOARD OF HEALTH (AND PUBLIC
2) 'SYSTE.N1 N'I,ll FAIL UNL 'WAT
ER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER,THAT PROTECT.THE PUBLIC HEALTH AND SAFETY"AND THE
ENVIRON%TENT: ,
G l-.
fi me ?\step, nd` a >epm tdnK allU Wi; d6borplton sys tn(and (i N.nluli 100 fe2i . o Su��a�c :.ail.; SurN!')
surface water supply. .
The s\sten ha, a sent c tank and soil absorption system;and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within So feet of.a private water supply well.. ,
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia-nitrogen and nitrate nitrogen is equal..tAor fens than S .
D] SYSTEM FAILS;
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR`1.5.303. The basis. "
for this determination. is idertUfed below.. The Boa Health'should be contacted to determtne;what will be necessary to correct,'
the failure. b:
Backup of sewa a into facility or system component due to an overloaded or,clogged SAS or cesspool.
g
Discharge or ponding'of effluent to the surface. of the,ground or surface waters due to an gvrloaded WOOS* SAS or
cesspool. �.
Z:
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION (continued).
Property Address:
Owner:
Date of Inspection:
D)SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to,clogged or obstructed pipe(s).
Number, of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -
Any portion of a cesspool or privy is,within a Zone l of a public well:
Any portion of a cesspool or privy is within 50 feet of a private.water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water,analysis for,
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in.addition to the criteria above:,
The design flow of system is 10,000 gpd or greater.(Large System) and the system is a significant threat to public health and safety
and.the environment because one or more of the following conditions exist: a;
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply welli
The owner or operator of any.such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 31.4 CMR'5.00 and 6.00. Please consult the local regional office of the Department for further.information.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B. -
CHECKLIST
Prope ss:
Owne `
Date of Inspection:
ae
Check if the following have been done: -
�Pamping information was requested of the owner, occupant,-and Board of Health.
one of the system components have been pumped foe 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 syste..m recently or as part of this inspection.
` "built plans have been obtained and examined. Note if they are not available with N/A.
_ h, facility or dwelling was inspected for signs of sewage back-up.
_j..,Ke system does not receive non-sanitary or industrial waste flow
�6 e site was inspected for signs of breakout. .
l.-ft?l'system components, excluding the Soil Absorption System, have been located on the site.
e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles.or
tees, material of construction, dimensions, depth of Liquid, depth of sludge,.depth of scum.
The size and location of the Soil Absorption.System on the site has been determined based on existing information or e
approximated by non-intrusive methods.
if diffPrant frnm:owner) were Orovided with information On the proper maintenance Of Sulr
Surface Disposal System.
,t
(revised 8/15/95) 4
III
SUBSURFACE SEWAGE DISPOSAL,•SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property -�� MCL(AICA.9-'
Owner: _�.
Date of Inspettr
FLOW CONDITIONS
RESIDENTIAL:Design flow: 'A0r all ns
Number of bedroos V\�d�'n \S beer O -C-3 ��
Number of current rmesid: ents: a� �`� a .
Garbage grinder (yes or no):ESP,. ,
Laundry connected to system (yes or no)- eS =
Seasonal use (yes or no): nd
Water meter readings, if available: f
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: allons/day
Grease trap present: (yes or no)_ :•:
industrial Waste Holding Tank present: (yes or no), & t
Non-sanitary waste discharged to the.Title 5.system: (yes or no)
Water meter readings, if available:
Last date of occupancy:___,._ _
OTHER: (Describe)
Last date of occupancy: r
GENERAL INFORMATION
PUMPING R RDS and source of in orrmation: •
System pumped as pan of inspection: (yes or noS- "
If yes, volume pumped 30.00 Fallons
Reason for pumping: �( Q►_0'��C t\C SL #
TYPE OF SYs
X M
eptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy r
Shared system (yes,or no) (if yes, attach previous inspection records, if any)
Other(explain)
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' 8/15/95) } 5
SUBSURFACE SEWAGE,DISPOSAL;SYSTEM.INSPECTION FORM
PART.0
`SYSTEM INFORMATION (continued)
Property ress:
Owner:
Date of Inspection:LA`l`ot qb - -
� ,
SEPTIC TANK:J�
(locate on site.plan)
Depth below grade:-" ,
Material of construction: oncrete _metal _FRP_other(explain)
Dimensions:
Sludge depth;
Distance from top.of sludge to bottom of outlet tee or baffle:
Scum thickness: it t`
Distance from top of scum to top of outlet tee or baffle: . t i
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
h f liquid level in relation to outlet invert structural
(recommendation for pumping, condition of inlet and outlet tees.or baffles depth qu d e �e S
integrity,"evidence le etc.) `�`
1 Q
GREASE TRAP
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal FRP _other(explain)
Dimensions: _
Scum thickne,,,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni cril- to hottom of outletj tee o►.:baftle
,
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.i
revised 8 4
1 :5/95) 6/
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART.0 ,
SYSTEM. INFORMATION (continued)
Props
Owner: „
Date of Inspection; `� � :
TIGHT OR HOLDING TANK:C1
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal FRP other(explain) g
Dimensions: `
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet.tee, conditionof alarm and float switches, etc.).
jL
DISTRIBUTION BOX: C} .
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level ano distrluutwr, a ryuai, e� u�i-tce of solid: cd:,)o,er, e�idenc i e,of leakage nto or out of box,
PUMP CHAMBER:
(locate on site plan)
Pumps in workingorder.(yes or'no)
.y,,.
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.).
(revised 6/15/95)
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART.C
SYSTEM INFORMATION (continued)
Prop dress:. .'V'1
Owner:
Date of Inspectro
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required; but may be approximated by non;intrusive methods)
If not determined to be present, explain:
Type: Q
leaching pits, number. tCo
c)
• leaching chambers, number:_ ..
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Com nts: (note condition of soil, signs of h draulic'failure'level of ponding,-condition ve etation,etc.
Q \�
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:=
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: _
Indication of ground..atc-
inflow.lcesspooLmust.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: - m
Comments: (note condition:of soil„signs of hydraulic failure, level.of,pond ing;;condition of vegetation, ete:) -
8
(revised 8/15/95)
s.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ....
SYSTEM INFORMATION.(continued)
Property dress: .Dl"'
Owne
Date of I�ton-,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
_ O
MAI
A
A6
(�C 3
DEPTH TO GROUNDWATER
Depth to groundwater:�feet c
method of determination or approximation_��lCrSM - )da
(revised 8/15/95.). 9
TOWN OF BARNSTABLE
LOCATIONf�Z 42 SEWAGE # a4Da'�S7S
VILLAGE ASSESSOR'S MAP & LOT 673 J
INSTALLER'S NAME&PHONE NO. /�¢ ���10 ��g 775 8 QO
SEPTIC T K CAPACITY �� 1' `f'�` �Q O B S
LEACHING FACILITY: (type)" (�w /N// t,-4la-s (size) //�x f��j X 10
NO.OF BEDROOMS
A
. BUILDER OR OWNER
PERMITDATE: f r _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 leachin facility) Feet
. Furnished by
&O
rn \
, . 01 , a-
Sk 24036 Pw343 053253
07-16-2009 03a240 -
DIEED RESTRICTION
WHEREAS. AEyAM= C of
sums)
o_c5 M
t AIM ISA Vgh;g MA
Is the owner of 60=6q Al Located
at ey&Yv 5_ N{Ar ` 'U'6&
MA(hereinafter referred to as h t4lQ -5 ,,y& _
and bpjng shown on a plan entitled"Subdivision o La d in
H Man A 5 MA, Property of. A
et al, LO f S duty recorded in Barnstable County Registry
of
Deeds in Plan Book Page .
64 Or on Land Court Plan Number
WHEREAS, 4 as the owner of said lot has
(ouaeeYa same .
—4 agreed with the Town of Barnstable Board of Health to a restriction as to the
—� number of bedrooms which can be included In any home built on said lot as a '
%J pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15.000 State Environmental Code,Title V. Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS,the Town of Barnstable Board of Health, as a pre-condition-to
granting a disposal works construction permit for a septic system in compliance
with 310 CMR 15.200, State Environmental Code,Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing
the Issuance of a building permit for the construdon of a single family home on
this property, is requiring that the agreement for the restriction on the number of
bedrooms In.any'hodge constrUcted on the lot be put on record with the
Barnstable County.Registry of Dees qy recording this document,
�esQr •
0JL
I
i
8k 24036 Pg 344 #53253
NOW,THEREFORE, does hereby place the
- .(ovtrtet'B name)
following restriction on his abov"ferenced land in accordance with his
agmnmeot y&htbs Town of Ramsta. ardaINAPHIM .
run with the land and be binding upon atl•sucoessors in tide:
1. 0 - G 41 Ala,Jbj P ied -j6Lqniz4:S may have constructed
(eddme)
u on the lot a house contarnr no more than J�{�bedrooms. `
DLr VE(�#- agrees that this shall be.permanent deed
(a�rreer's name)
restriction affecting located on IVIA, and .
being shown on the plan recorded In Plan Book , Paged
Or on Land Court Plan
For title of seethe following deed: Book . , Page
Or land Court Certificate of Tide Number
Executed as a seated instrument day of_�•
Owner's signature
Owner's signature"
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
Barnstable ss '
1ra 2009 .20
Then pe orb anillYAR the above-named.
known to me to be the person who executed the foregoing Instrument and-...-M _
-�,
acknowied AleSS Drivers licereCe
the same to be rn free act and d d► f:4•� �`:>~'.;u'' �4, `-
N
Public oil4•' s-
My c 1010" .tAVfNdER ���r eae .-
� �� •u''A .ears
dot& BARNSTABLE REGISTRY OF DEEDS
TOP 20 FT. MINIMUM FROM CELLAR � �� ��� '
OP OF __
10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST IjQ��,�
ELEV. r i00'0_ 10 FT. MINIMUM CLEAN SAND SOIL TEST DONE BY cw1WF �.R-�lEEE3tdG
(ASSUMED) CONCRETE WITNESSED BY
COVERS T-INSPECTION PORT 08MVAT" HOLE 1 ELEV.--_98.80
4" SCHEDULE 40 PVC PIPE LOAM AND SE.:D
MIN. PITCH ?/$" PER FT PERCOLATION RATE __L�__ MIN./INCH AT 50" INCHES
\, 2" LAYER OF r—
1/8" Tr, 1/2" LEGEND:
DEPTH HOR12 TEXTURE COLOR MOTT. OTHER
_ 1 WASHED STONE I..GVG
3.� 4" CAST IRON PIPE MOD MAX fid.3S MIN. � REQUIRED EXISTING SPOT ELEVATION 00„0 0-12 Ap LOAMY SAND 10YR3/3 NO
(OR EQUAL) MINIMUM EXISTING CONTOUR - --00----
Z FINAL SPOT ELEVATION 12-40 I B LOAMY SAND 10YR5/8
PITCH 1/4 PER FT. \ I _
FINAL CONTOUR
TEE �J�' vet, SOIL TEST LOCATION � 40-126 C COARSE SAND 2.5Y7/6 20% COBBLES
FLOW LINE quo a' UTILITY POLE -0-
10" 141
TOWN WATER —W W—
' ' _ c �—
ELEV. --rMIN. I �5�� � 0" o o I - o CATCH BASIN
T L V. _ _ L VEL o 0 low, ELF. = GAS LINE
GG
ELEV. _ _ ELEV = _ 9S_50 -1 6" SUMP ELEV. _ 1 ------ CLEAN 0 T C.O._�••�-
BAFFLE DISTRIBUTION RIBUTION ELEV _ CESSPOOL C.P. Q y
LIQUID OUTLET 80V /Li_20) 8 NIGH CAPACITY INFILTRATORS WITH ( L j, t,
/X `fl L I _QS.1Q_ STONE IN AN
DQTH TEE (TO 8E PLACED ON A FIRM BASE; `: 5E WATER TESTED = ?
4 FEET 14 INCHES
5 FEET 19 INCHES 1 /� MGRE THAN ONE OUTLET 11 XN48 X�10' TRENCH H FORMATION
6 FEET 24 INCHES i 500 GALLON SOIL ABSORPTION NO WATER ENCOUNTERED AT __126" ELEV. _ _-88,3.0.
NE
8 FEET 34 INCHES SEPTIC TANK T`- BE PLACED ON FIRM BASE] J WELL N A 1 �' r "', , ' -,;Y
3 '4" TC 1 ? 2" CLEAN NDEA
DOUBLE WASHED STONE SYSTEM (SAS) ADJUST
FREE OF SINES & SILT USGS PROBABLE 2 � DESIGN CALCULA�ONS
WATER TABLE ELEV. t ______
NUMBER OF BEDROOMS _-4__
SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ` ELEV. = ------ GARBAGE DISPOSAL UNIT
BOTTOM OF TEST HOLE ELEw _ _aQ_ TOTAL ESTIMATED FLOW
$.
( 110 GAL/ t/DAY X _4 BR.) -J00- GAL./DAY
REQUIRED SEPTIC TANK CAPACITY GAL.
ACTUAL SIZE OF SEPTIC TANK (DOSMG) _1 GAL.
SOIL CLASSIFICATION
DESIGN PERCOLATION RATE Ste__ MIN./IN.
EFFLUENT LOADING RATE GAL./DAY/S.F.
LEACHING AREA Nil
SQ. FT
(11 X48)+(59=10/12)
LEACHING CAPACITY (AREA X RATE) 443LM GAL./DAY
626.33 X 0.74
RESERVE LEACHING CAPACI T Y NOW GAL./DAY
NOTES:
1 ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO O.E.P.
TITLE 5 AND THE TOWN OF - SAAM4TAM — RULES AND
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 1
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO f
WITHIN 6" OF FINISHED GRADE. i
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
4 aNy MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL
PPr) IN PLACE.
as 04,r S�jrr FENCE NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
DEEDED OR ZONING REGULATIONS OWNER ; APPLICANT IS TO
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
6 UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS
TP 10000. PRIOR TO COMMENCING WORK ON SITE.
/ !l00, 7. CONTRACTOR IS TO VERIFr GRADES AND ELEVATIONS AS WELL AS
I _ SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION
• ' y - IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
r ' IMMEDIATELY.
T J I C_0 `' C 0 _ 8 PARCEL IS IN FLOOD ZONE
1500 GALLON 99.E �y 9. 'LOT IS SHOWN ON ASSESSORS WAP _ N7__ AS PARCEL
4 SEPTIC TANK - 10 SANITARY TEES ARE 10 BE REPLACED IN SEPTIC TANK (IF REUSED).
11 EXISTING LEACHING PITS ARE TO BE PUMPED AND REMOVED.
12 ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER AND FOR
'�/S UC �H Of A MINIMUM OF 5' AROUND SOIL ABSORPTION SYSTEM AND BE REPLACED
D. BOX �
\ 0 o,v \ � WITH SAND AS SPECIFIED IN 310 CMR 15.255:(3).
r ' ~ S1 1
A T ^
ze s „ s
gy. y4 5
VENT APPROVED: BOARD OF HEALTH
o \ G '�
i 99 6 4
ror 8 / 99.2 099 " DATE AGENT
AREA 8,1701 S.F.
pKr F 98.9
9 PROPOSED SEPTIC DESIGN '
EiyC GRA✓EC i
DRi VE ,( I I FOR '
\ r
07 , I
a ALICIA VOEG U
,00 o0,
98. /
O PROJECT LOCATION LOCUS 8
60 a4 NAUTICAL RD, URNSUBIX
SWMM R JMBIAZR
235 GREAT WESTERN ROAD
508- P. 0. BOX 713 '
+ 398-3922 SOUTH DENNIS, MASS. 02660
1 -- k
DATEDATENOV 19, 20 2 SCALE ,� 2
x
i
NANIUCKEr REV. DEC. 9, 2 0 0 2 JOB No. 55W 3 00 '
50il D .�
LOCATION MAP REv. SHEET 1 1
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F8K 192128 C. S8 PRO✓ 5583-00'dw 558J-00.DWU 02002 SWEETSER ENGI