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0022 NORRIS STREET - Health
C71122Norris Street1 E V4 rr F/R 042 _ __. - --- i 1 d p SEWAGE INSPECTIONS 'LOCATION r off° iDATE j 3 Lou VILLAGE � TZ -INSPECTOR SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS ,BUILDER OR OWNER VVER OWNER MAILING ADDRESS . I� �6; „ _ i -, �I 4, � ,� -, ' �\ �� \ `� l� r TOWN OF BARNSTABLE LOCATION /CO',Ge"o I S -1" SEWAGE # VILLAGE #40640A f. A4*. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 -. �� � ��� � .- J No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for 33i.5po.5ar 6pgtem Con!5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(Y\) El Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel "3 4i- �}l 30 O o Installer's Name,Address,and Tel.No. � �`�"75—`6� q Designer's Name,Address and Tel.No. . nt1t�'dxtc��17 QU Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0"I i� fe k 14 CAlsG C Rai e--)eo E)Ix c. m A-0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been' y this Board Health Signed _ a m Date � 4 Application Approved by AZXWZZL Date lu Application Disapproved for the following re o Permit No. Y 7 Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEa, MASSACHUSETTS ' Application for 3W.5pp l *p5tem t(Con5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( �) ❑Complete System ❑Individual Components Location Address or Lot No. A Owner's Name,Address and Tel.No. a8. O�`s'�ra � � +�y�lf����.• `1�q�-c�tc.�0. 1�0�k 1S Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �S�>7�5``3�J�J� Designer's Name,Address and Tel.No. E Uy..11oLwmUY'00 ls�:?!7 PC..J=1tzi►lR ,01 A. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons-per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) fO M 1� Pn,iJ W. ck C Q QOO �Ct 2. tXl l e +DU3 fX 'akW2r- Date last inspected: 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been 's u ._by this Board o_ H alt Signed. o Date (JO V i C ,D Application Approved by Date Application Disapproved for the following re o s Permit No. Date Issued �:...; = THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded( ) Abandoned by j• 11Aw0►y\,6 R djG bon at &&, VIC)I-f 1 S I 4-�ClaTUI!S ! a ha e -constructedgin accordance with the provisions of Title 5 and the for Disposal System Construction Permit No '� dated 1( 10,u tl Installer Designer The issuance of this permit shall not be construed as a guarantee that thej em will unction >.de igned. Date I I i)�I Inspector 7 rn v No. ! 2D�, i ` — Fee ,7---------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES-MASSACHUSETTS Migogat *pztem Congtruction Permit Permission is hereby granted to Construct( )Re it( )Upgrade( )Abandon(y) System located at 1lY) 15 r 'l<� r • 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: Cons ctio must a completed within three years of the date of thi e itJ Date:_�(/ // Approved by No. / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migozaY *p!5tem Con5trurtton permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon(x) System located at 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:Cons ctio must 'e completed within three years of the date of thi e i Date:_ Approved by I r , t Permit No.: TOWN OF BARNSTABLE DEPARTMENT OF PUBLIC WORKS SEWER PERMIT Connection: X Modification: Disconnect: Repair: Assessors Map No. 306 WATER SUPPLIER: Assessors Parcel No 042 SEWER ACCOUNT NO.: Street: 22 No z zi-6 St2eet SEWER ACCOUNT NO.: / Village: fLyannLb /7a4b 02601 PERMIT FEE: $ ��U / ��� ( ".-�sy Septic Abandonment Permit (1)Residential Bldg=$420.00 (each addt'I.bldg.on same service=$200.00) Obtained From Health Department: ��W — 9/ (1)Commrc'I.Bldg.=$875.00 (each addt'I.bldg.on same service=$200.00) Connections requiring installation of a pump,add$300.00 to base charge. Abandonment Permit Not Required: PROJECT CONTACTS PROPERTY OWNER(Mailing Address SEWER INSTALLER Name: P ataicia Nopkinh Name: I••% Macomgen & Son Inc(Rogezt P toii. Address: 3 9 8 .At h e a t o n z S t a e e t Address: Box 66 miiion Ma 02IR6 Centeltvieee Na 02632 Phone: 617-333-0139 Phone: 508-775-3338 PROJECT DESCRIPTION REGULATORY REQUIREMENTS The installation of all sewer connections must be done in accordance with FACILITY&LAND USE DATA the provisions of Article XXXVI,Town of Barnstable,General By-laws and regulations issued by the Department of Public Works. Before excavating NUMBER OF UNITS METER SIZE FIXTURE NO. within a Town Way the sewer installer must also obtain a Road Opening permit and comply with the Construction Standards and Specifications RESIDENTIAL: i outlined therein. At least 48 hours prior to the installation,the applicant must notify the Department of Public Works,Engineering Division for the COMMERCIAL: purpose of inspecting the installation. The Inspector will complete the Compliance Sketch locating the installed lines and connection. RESTAURANT: INDUSTRIAL By,signing the Application, the applicant acknowledges and understands the regulatory requirements and understands that failure to comply with them shall be grounds for revocation of the Sewer Connection Permit and STANDARD INDUSTRIAL CLASSIFICATION NO.: the denial of any future application. This sewer connection permit shall be NO.OF BUILDINGS: NO.OF BEDROOMS: _ valid for 180 calendar days from the date of D.P.W. approval indicated below. The required notice must be given and the installation SIZE OF PARCEL: _ ACRES: commenced before the end of that period. Otherwise, the permit shall become invalid. When that occurs,a new permit must be applied for and ESTIMATED DAILY SEWAGE: v�GALLONS a new fee paid. PIPING: LENGTH DIAMET R 7 �(S(-� I G� Detailed engineering drawings must be submitted with each commercial permit application and be approved prior to acceptance of this permit. EXPECTED INSTALLATION DATE: SIGNATURE(INSTALLER): DATE s SIGNATURE(DPW APPROVAL) DATE 0 THIS PERMIT EXPIRES ON: FORM.Sewer Conn.Form(REVISED 02J03) r FAILED INSPECTION DATE-8/03/04 -- PROPERTY ADDRESS: 22 No22.iz_St. - - -- RECEIVED llyann.iz, t7a. AUG 2 7 2004 02601 ----`-------------- TOWN OF BARNSTABLE HEALTH DEPT. On the above date, the septic system at the above address was O Inspected. MAP � �.� �� —� This system consists of the following: PkRCEI" 4 2- 1. 1 zing-ee 6 'X6 ' ce.6,312oo.e t 0-r a _ 2. 1 6 'a2m o�� cenzpooe that dead end,3 with no 's.tone Based on inspec ion;n�ce°rti#y �ie '>o�l�ow ng conc3i io e 3. 7h.ir -i.6 no.t a .tz.tie�ive- hept.ic zyz;tem. 4. 7he 3yztem .ih .in hydzau.e.ic /a.i.euae 5. the* wazte ' Ovate z wah 4" �aom .inveat 12.il2e .in ce.,3,3/200-e 5. The dwe.e-e.ing can &e tied .into town zewe2. SIGNATURE- - - N a me:Company:-- I.I. P--facomPetii,and_zon_ Address:___kD_x__ 6-6--------------- CenteIzv.i.e.ee; Na. Phone: (,508)775-3338 ----------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY slow P I'a :OS.EH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped .& Installed Town Sewer Connections ox 66 Centerville, MA 02632-0066 775-3338 775.6412 s i COMMONWEALTH OF MMSACHUSETTS EXECUTIVE OFFICE OF ENVIRO rNM''�NTAL AFFAIRS d DEPARTMENT 07NVIR4NMNTALpROTCTION w TITLE 5 OFFICIAL INSPECTION FORM—.N0 T;FOR.VOL`NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION. Property Address:'• uv^nn; MD !1'�G �• Owner's Name: Owner's Address: Date of Inspection: . .. . ... Name of Inspector: (please print) • -• - CompanyNamo; 7 % �acom /t & .S.on Lac• Mailing•Addtess: o b F.0 2 6 Z Cen e�z� �. -` Telephone Number: 5 0 CERTIFICATION STATEMENTion po have person inspected the sewage disposal system.at this address and tha -the- -f basat on my ed I certify that I p below is true;accurate and complete as of the time of the inspection.The inspection perform training and experience in the roper fiinction and mai tenance of on.qite sewage 40 of T le 5(31 CMR 45000)disposal system: a DEF . approved system inspector pursuant fo Section 153 , Passes Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fails Inspector's Sigaitn're: l submit a copy of this inspe ction.iepolfto the.Appioving Authority.(Board of Health or The system inspector shal DEP)within 30 days of completing this inspection.If the ubmit the report to the appropriate opnate egional office of the gpd or greater,the inspector and the system owner.shall DEP.The original should be sent to•�the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments **** ort only describes conditions at the time of inspectidn'and under ub underit ons same of a at-that ant This rep y ^ time.This inspection does not address.how the system will perform to the conditions of use. _. 411 v1)nnn page I . I Page 2 of 11 OFFICIAL INSPECTION TORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � A PART A CERTIFICATION (continued) Property Address: 99 7nrr i s C t:=aQ t Hyannis Owner: P6t or _ lZr _ _ Qen sohn Date of Inspection: Inspection S.vm`mary: Cheek YA;B C,D or.E/ALWAYSyeomplete=all of Section., " A. System Passes: no. I have not found any information.which indicates that any of the failure criteria described yin 310 CMR 15.303.or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: LOne or more system components.as described in the"Conditional Pass"=section need to be replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal.and over 20 years old*or the septic-tank(whether metal.or:not)is.ztructurally unsound,exhibits substantialm infiltration or exfiltration or tank failure is:i.rminent. System will pass inspection if the existing tank is replaced with'a complying septic tank..as-pproved by the:Board of Health. *A metal septic tank will pass inspection if it is'structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less.than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection If(with approval of Board of Health): broken.pipe(s).are replaced. obstruction is removed distribution box is leveled or feplaced ND explain: The system required pumping.more than 4 tunes a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI,ON.fORM PART:A CERTI.FICATION'(continued) : Property Address: 22 Norris Street Hya_nni.s Owner:. Peter Friedensohn Date of Inspection: R/314 0 4 A C. Further Evaluation-is Required by the Board of Health: Conditions.exist which require further.evaluation.bythe•BoardofHeaithin order.to:detettnine if.the system is failing to protect public,health, safety or the environment. 1. System will pass unless Board of.Health determines-in at. c'ordance with 310.CMR 15.303(1)(b)that the system is not functioning in.a mannerwhich mill.protect public health,safety and thv.-environment: Cesspool or privy is within 50 feet of a.surface water M Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health(and Public Water Supplier,-if any)dhtermines.that the system is functioning in a mariner 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.sepfic tank and SAS and the7,SAS is within a Zone 1 of a--public water.supply. The system has a septic tank and.SAS and-the-SAS is within.,30 feet of a private water.supply well. l The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet or-niore frorA a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from}that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered. A copy of the analysis must be.attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM_NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 29 orri c St-rPat Owner:_t4ccr-�' fe�o #s0_''^�-- Date of Inspection: Quin n D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the.following1or all inspections: Yes Np _ . ✓� 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 —7 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. — Aq.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply. ✓ Any portion.of a cesspool or privy is within a Zone i of a:public well.. _ Any portion of a cesspool or privy is within.50 feet of a private water supply well. _ Any portion of a"cesspool or-privy is less than 100.feet but greater..than 50 feet from a.private water supply well with no acceptable water quality analysis. [This system.passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution;:from:.that facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are-triggered.A'copy of the analysis must be attached to this forte.] ,)QC (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,the 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 1%000 gpd to 15;000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — the system is within 400 feet of a surface drinking water supply pw 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 amapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS W11SURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART CHECKLIST Property Address: 2 2 N o r r i ss s txa__ _H n n i c Owner: Peter Frj aannsohn' Date of Inspection: al pa, Check if the following have been done You must indicate')Ts"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 its N/A) l_ Was the facility or dwelling inspected for signs of sewage back up? �� ✓ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site.? Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dlmensions,depth of liquid,depth of sludge and depth of scum? ifferent from owner)provided with information on the proper Was:the facility owner(and occupants if d maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)on the site.has been detetniined based on: Yes np — _ 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 02(3)(b)] is unacceptable) [310 CMR 15.3 . 5 I , Page 6 of 11 OFFI:-IAL MNSPF CTI°O T VORM`-NOT FOR VO.I INTARY ASSESSMENT'S SUBSURFACE- -SIDWAGE OISAOSAUSYSTMINSPECTION FORM � PART'.0 SYSTEM-INFORMATION Property Address: 22 Norris Street Hyannis Owner: Peter Friedenaolan Date of Inspection: R/3/.0 4. , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -..Nwnber of bedrooms(actual): DESIGN`:flow-based on'310 CV& 15.203':(for eXainple:'1 10 gpd i#-of�ooriis): Number of current residents: .: Does.;residence have a garbage grinder(yes or no):rVO Is laundry on a separate sewae.system(yes or.no):. [if yes separate inspeption required] Laundry system inspected(yes or no): ' 117,9-6 gPd c , 1 Seasonal use: (yes or no):I� .2 Poo, Water meter readings, if Yu�liable(last 2 years usage(gpd)): �1®g3° 'p�;I Ja = Iq I gp i) Sump pum (yes or no):_ Last date o�occupancy: COMMERCM USTRIAL '� Type of estab nt: , . . . � Design flow W. on'310 CMR 15.203):. pd Basis.of d6�6w(seats/persons/sgft,etc.):,ja6 Grease trappresent(yes or no):n Industrial waste holding tank present'(yes or no):K Non-sanitary waste discharged to the Title 5 system-(yes or no): Water.meter readings, if available: { Last date of occupancy/usgW—s OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: 7S. r ! w"-w dius Soh Was system pumped as part of the inspection(yes or no):j C If yes,volume pumped: 2)z allons--How was uanti pumped determined? 9F i.lq . Reason for pumping:����.► �� 1 pzc� j 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 airy) _Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) -�, _Tight tank. _Attach a.copy of the DEP.approval —Other(describe): Approximate age of all components,date installed(if known)and.source of information: Were sewage odors detected when arriving at the site(yes or no): 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Norris Street Hyannis Owner:_ peter Fr; -densohn Date of Inspection: R/'3 f 0 4 lr AfA . BUILDING SEWER(locate on site plan) Depth below grade:---- Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints ven ' . J , evidence�.Q : tn}g,/ of(leakage{,etc.). t v SEPTIC TANK: (locate on site plan) Depth below grade: M Material of construction:}concrete&metal,l fiberglass4�r_polyethylene _other(explain) If tank is metal list age: I Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: lam, Sludge depth: VV\ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:; < _ Distance from top of scum to top.of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined; 0j\ Comments(on pumping recomrriendations,inlet and outlet tee or baffle condition,structural integrity,as related to outlet inve evid ce of le ge,etc.): liquid levels GREASE TRAP:}(locate on site plan) Depth below grade.:K Ah Material of construction:YA concrete&metal flAfiberglass_�polyethylene other (explain): Y% 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: VA k, �- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaks e:,etc.): i Titln C Tnenrarfinn 17nrm Fn,;i,)nnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS S l3S Rk':A►CE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:22 Norris Street Hyannis Owner::.---EE3tex' oaor,� �n Date of Ihspection: g i 3,�-a 4- _ TIGHT or HOLDING TANK: , t (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: Material.of construction: concrete ometal �L' fiberglasst olyethylene other(explain), Dimensions: Capacity: .ga)lons Design Flow: gallons/day Alarm present(yes or no) Alarm level: 0 yam_ Alarm in working order(yes or no): Date of last pumping: Comments(condition of ai.arm and float swi ches, etc.),, DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invem" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leaka a into or out of box, etc.): PUMP CHAMBER:L -000cate on.sife.plan) Pumps in working order(yes orno):60 Alarms in working order(yes or no):{- Comments(note condition of pump chamber. CPAdition of p mps,and appurtenances, etc.): 8. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONYORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Norris Street Hyannis Owner:. Peter Pri edensohn Date of Inspection: 8/3/0 4 �n SOIL ABSORPTION SYSTEM(SAS): '� (locate on site plan,excavation not-required) If AS not.Icated�explaimn why:S �t � r� [ Type leaching pits,number: leaching chambers,number: leaching galleries,number: iN�leaching trenches,number,length: My—leaching fields,number,dimensions: t10 overflow cesspool,number: 1.0 innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:�Co)CCo Depth—top of liquid to inlet invert: Depth of solids layer: too Depth of scum layer: ��r Dimensions of cesspool: Materials of construction Indication of groundwater inflow(yes or no):9k Comments(note condition of soil, signs of hydraulic failure,level of pondin ,condition of vegetation,etc.): © 123rl ' . w PRIVY: (locate on site plan) Materials of construction: Dimensions: V Depth of solids:IRK m l gns o hydrauic failure,level of ponding,condition of vegetation,etc.): Comments(note conditg of oil,si 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE(DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addresr. 22 Norris street u��s Owner: Peter Fri -d -nsohn Date of Inspection: R/-1/rr4 ' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or. benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. r iY- �r � rl • v . . ,,10 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Norris Street Hyannis Owner: . Peter Friedensohn Date of Inspection: 8/3/0 4 r^ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �� feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 1' 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 es blis ed the high grou d wa r elevation 1)S6 u dR. t�r►t� U�cA air @NNE g;2 J���� f s o ::'ry 4 u*4 t 2 C. In rove I I � C .30 om U OJIA `I Titles S Tnonorfinr%Fnrm 4/1 si')Ann 11 • ! . Az)-- 11 OWN OF Bar stahlP_ WARD OF HEALTH SUIISURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- Can F1CATION ,•••4I•I_T.:-::,-T.t ifl�•T.TT17A1`wi'RTM T'RT�•«1T -TYPE Oft PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS Norris 22 Nis Street Hyanni c. MT 09601 - , ASSESSORS MAP , BLOCK AND PARCEL # 306-04 OWNER' s NAME Peter Friedensohn PART D - CERTIFICATION NAME OF INSPECTOR Bruce COMPANY NAME Joseph P. Macomber & ri Inc. COMPANY ADDRESS Box 66 Centerville MA 02632 Street Town or city state LIP COMPANY TELEPHONE ( 508 ) 775 _ 3338 FAX ( 508 )790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, a nand any omplete as of the time of •inspection . The inspection was recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR. 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this, form. System FAILED* The inspection which I have con\--a-rdted has found that the system fails to Protect the jiublie health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - ILAILURE CRITERIA of this inspection form . Inspector Signature Date 63 e copy of this certification must -be provided to the OWNER, the IIUYER On where applicable ) and the pOAttD OF HEALTH. * If the inspection FAIL,41), the owner or operator shall upgrade ' the system. within o'ne year of the date of the inspection., unless allowed or required otherwise as provided in 3jo chI.R 16 . 305 . partd.doc y �' I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS >r DEPARTMENT OF ENVIRONMENTAL PROTECTION I d a i TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FO tM ffffTV PART A CERTIFICATION AUG 5 2002 O 0�� TOWN OF tiAFtNSTAu G Property Address: 22 NORRIS ST HYANNIS, MA 02601 Q HEALTH DEPT. Owner's Name: MATTHEWS Owner's Address: 22 NORRIS ST HYANNIS, MA 02601 ,� Date of Inspection: 7/22/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section t1,5.340 of Title 5(310 CMR 15.000). The system: X Passes o _ Conditionally P sses _ Needs Furt valuation by the Local Approving Authority Fails Inspector's Signature: /n Date: 7/22/02 The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec ion. I('tl�e system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional on-ice of the DEP.Tile original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG TI IE SYSTEM'S USEFUL LIFE. I ****This report only describes conditions at the time of inspection and under the conditions of use al that lime.This inspection does not address how the system will perform in the future under the same or different conditions of use. r...... G/lc"ioo1 r .. Irk^ •`. �_ r '.� ' s .•y -.. . - - - 1, q,: -,.f•r �} by • .. - - .. a�, .} A Page 2 of 1 I },t z. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 22 NORRIS.ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 Inspection Summary: Check A,BC,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria'not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. "fr, 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 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 inspectioniif 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�break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a `,4' `IA r„ 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 Ad*Board of Health): _broken pipe(s)are replaced obstruction is removed ltt�iT ' t ND explain: n/a ! ` 1 Page 3 of 1 '�'• tt OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ti CERTIFICATION(continued) Property Address: 22 NORRIS,ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 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 tti'e 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: ^t _ Cesspool or privy is w;thin;50 feet of a surface water _ Cesspool or privy is wifhin',50 feet'of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment:. _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water'supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. •�1,1 , 5 _ The system has a septic tank &SAS and the SAS is less than 100 feet but 50 feet or more from a private water t�. supply well". Method used to'deterinine distance n/a "This system passes if the,well water'analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoun�sandicates 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. ( 1 3. Other: n/a 1 11.t 'ir `t '1, Page 4 of I 1 s . OFFICIAL INSPECTION`FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �.> CERTIFICATION(continued) Property Address: 22 NORRIS ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ X Required pumping more than tirnes in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of ces'spoof''or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or pri,Jy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water qualityanalysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for:coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.I';, (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. 6 E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to,,large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 20,0 feet.of a.tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well .. .,, 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 lame system i Iias.failed.The owner or operator of any large system eunsidered a-ig11 1 and threat under Section E or failed under:Section D shall upgrade the system in accordance with 310 CMR 15.304. Tile system owner should contact the appropriate regional office of the Department. Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE<SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: 22 NORRIS ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 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 X Were any of the system components pumped out in the previous two weeks`? X _ Has the system received normal flows in the previous two week period`? X 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) i.. X _ Was the facility or dwell'in1g inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out'? X _ Were all system components;.exc;uding 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? , The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For exapn!ple,a plan at the Board of Health. X _ Determined in the field.(if an' of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(30)] F y tf J, I, t Page 6 of I I j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r. SYSTEM INFORMATION Property Address: 22 NORRIS ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 ;, FLOW CONDITIONS RESIDENTIAL „� Number of bedrooms(design): N,umber of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 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- Seasonal use: (yes or no): NO � p Water meter readings, if available(last 2 years usage(gpd)):4�p OC)— Lke e bop Sump pump(yes or no): NO o' ��/ l Ott Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203):=.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: n/a: Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-'.How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy ; _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and mzintenance contract(to be obtained from system owner) _Tight tank Attach a copy,of the DFP approval Other(describe): n/a Approximate age of all components;date installed(if known)and source of information: 1959 BY AGENT Were sewage odors detected when arriving at the site(yes or no): NO k 4' Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE�S'EWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 NORRIS ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 BUILDING SEWER(locate on site plan)' Depth below grade: 18" Materials of construction:_cast iron _40 TVC Xother(explain): CLAY Distance from private water supply well 0r,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: 12" Material of construction: Xconci•ete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a lsiage conf rmed'by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:Y X 3' BLOCK CFS,S'POOL"-,` Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" 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: 16" 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.): MAIN CESSPOOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan),... y. Depth below grade: n/a Material of construction:_concrete_rrietal'_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 Fw Comments(on pumping recolllni�i tdations, inlet and outlet tee or baffle condition,shuctural integrity, liquid levels as related to outlet invert,evidence of leaf age,,'eeL):. n/a �`, . . V .4k .ir k,If, F. 7 Page S of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 NORRIS ST HY'ANNIS,MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 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 i,me'tal_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 ti Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must'be.opened)(locate on site plan) 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. or out of box,etc.): n/a PUMP CHAMBER: -(locate on site plan) t. 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 A,110"alik s' f Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 NORRIS ST HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a I leaching trenches, number, length: 15 , n/a leaching fields, number: n/a n/a 1. overflow cesspool, number: n/a n/a t °';';;innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): TRENCHE IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 5 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a 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 Materials of construction: n/a Indication of groundwater inflow(yes or 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)" ` 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,condition of vegetation,etc.): n/a 4 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 NORRIS ST HYANNIS,MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 SKETCH OF SEWAGE DISPOSAL-SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. f w t •5 l l n Page I 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C x SYSTEM INFORMATION(continued) Property Address: 22 NORRIS ST,HYANNIS, MA 02601 Owner: MATTHEWS Date of Inspection: 7/22/02 SITE EXAM _Slope _Surface water Check cellar `k Shallow wells Estimated depth to ground water 8+feet 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-8+ FT. i f ,j It „r II ti Town of Barnstable s s + BARMAUE E + Department of Public Works Engineering Division 367 Main Street,Hyannis MA 02601 Thomas J. Mullen,Director Office: 508-862-4088 Robert A. Burgmann, P.E. Fax: 508-862-4711 Town Engineer July 1, 2002 RECEIVED Ms. Betty Mathews 22 Norris Street in 0 2 2002 Hyannis, MA 02601 TOWHEAL H DEPT.BLE Re: Sewering of Norris Street, Hyannis Dear Ms. Mathews: In response to your question about the sewering of Norris Street I offer the following information: 1. Funds for the construction of a sewer in Norris Street have been appropriated by the Town Council. 2. The design of the sewer by this office is approximately 85% complete. 3. State permits necessary for the construction of the sewer have been obtained. 4. The actual construction of the sewer could start as early as October, 2002. 5. The latest that I anticipate the construction beginning would be the Spring of 2003. 6. Construction of the project should not take more than a month. 7. Everyone on the street should be notified by the Board of Health to connect to the system by the Summer of 2003. I hope that this information meets your needs. Should you have any additional questions please contact this office. Ve truly yours, ob A. Bur , P.E. /Town Engineer CC: Board of Health Q:dpweng\wpfiles\burgmann\corres\2002\citizens\mathews Ldoc AAk Commonwealth of Massachusetts lose Executive Office of Environmentol Affairs Jo"Grace D.E.P. Title V Septic Inspector Department of P.O. Box 2119 D EnVlronmental Protection Teaticket, MA 02536 8. 4-6813 WUllam F.Wald I t Trutd Coze David B. Struhs Commissioner - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ✓(/� ���(// �I\� 3 b PART A 3 r 0 E t� CERTIFICATION � I9 y 1 , 96 Property Address: �� 0&j ��. Address of Owner: Date of Inspection: �4.�, (If different) Name of Inspector: �1 S �x� 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 my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _A,,:--Fasses Conditionally Passes _ Needs Furth Evaluation By the Local Approving Authority Fails Inspector's Signature: Dater �3��ct� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be Beni to :ne system owner anu cople� sen; IV tix buyer, if applicable and the appro.ing authority. INSPECTION SUMMARY: ChecoA,,B, C, or D: Ai SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310[MR 15.303. Any failure criteria not evaluated are indicated below. Bi 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 or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved.by the Board of Health. w . tigvised 8/15/951 1" f One Wlntar Street; • Boston,Massachusetts 02108 a FAX(617)SWI049 • Telephone(617)292-55W 40 Printed on Regcled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: Owner: (� - Date of Inspection: 81 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRO\MENT: i ne >%cieni nd� a >epiIC tanK anu Dun db5orption sy�len. and Is V.ii1'i i'i iuv fcc, :6 a Sui—Cc '. u C: S::NN!r 3, J u i air" t: surface water supply. The s\s!P-n- has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The s,siern 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 to or less than 5 ppm D] SYSTEM FAILS: I have determined that the system violates.one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified.below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. .(revised 8/15/95) 2 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE 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: 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 wells The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment pfogram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION fORM PART B CHECKLIST Propedress: (15 Owner: G�� Date of Inspection: �?,�\4f,, Check if the following have been done: LlUrmping information was requested of the owner, occupant, and Board of Health. {,Dlone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates .during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. C,y� s built plans have been obtained and examined. Note if they are not available with N/A. yK.The facility or dwelling was inspected for signs of sewage back-up. _f'The system does not receive non-sanitary or industrial waste flow L'The site was inspected for signs of breakout. _✓/QI system components, excluding the Soil Absorption System, have been located on the site. fhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or u 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 approximated by non-intrusive methods , �,,�, r�. ;f diffaran+ from ownP-) were provided with information on the proper maintenance of Sub- The Surface Disposal System. (revised 8/15/.95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner:`��t 6\\ Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: i stallons Number of bedrooms:1 Number of current residents: Garbage grinder (yes or no):QU Laundry connected to system (yes or no�if S Seasonal use (yes or no): C j Water meter readings, if available: Last date of occupancy: •;��1C(�t -� \Ct Ci� COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:+gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS.and source of information: System pumped as pan of inspection: (yes or no)f If yes, volume primped gallons 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) 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) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _,FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) - -- GREASE TRAP:_ (locate on site platy Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum tiuckiie». Distance from top of scum to top of outlet tee or baffle: n!Stance from botten, ni <rt,,r to hottom of oulle! tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of.leakage, eic.) I i (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _,FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) I .ti DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if levei and dutriuutiun i>ryuoi; e,-6ci,cv of sul,d�,ca:i)u,Er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber; condition of pumps and appurtenances, etc.) _ (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S-j-- Owner: \1 Date of Inspection: \ � SOIL ABSORPTION SYSTEM (SAS):�� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: _ leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comm s: (note condition of soil, sig s of hydraulic failure, level of ponding, condition of vegetation,etc.) S> en, CESSPOOLS: _V (locate on site plan) Number and configuration: C�Q - Depth-top of liquid to inlet invert: C�MOB Depth of solids layer: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: ind,cat,on of ground•.atr-. p.C� inflow (cesspool must be pumped as part of inspection) comments: (note condition of soil, signs of h draulic failure, ev nding, conditio of vegetation, etc.) Sc C�`(1�C. ,� �� G 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.) B (revised 8/15/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 Nod M Owner: Date of Inspedio}ht: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' fv �b N IONCA DEPTH TO GROUNDWATER Depth to groundwater: t 0 feet c method of determination or approximation: U JG S (GC S i-GnQ 4S (revised 8/15/95) 9