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0501 OAKLAND ROAD - Health
501 OAKLAND ROAD, HYANNIS A = 272 058 I TOWN OF BARNSTABLE LOCATION 7S O( ®AV—��yl�d � C�, SEWAGE# RO 15 �— VILLAGE <-) ( ASSESSOR'S MAP&PARCEL oZ7eZ. INSTALLER'S NAME&PHONE NO. dA �c'�,`c�c SEPTIC TANK CAPACITY 0 aia LEACHING FACILITY.(type) 0,S-pc5[�d, �� (size)ka-,1) a y NO.OF BEDROOMS 3 OWNER CE nE jtA t, �i4'T "l OZ i Ct ICE P1 SSOC PERMIT DATE: Ct 1 COMPLIANCE DATE: 9— $ 'aOly Separation Distance Between the: Gim—WTIUA-16 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Gue&t)Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) VIA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within / 300 feet of leaching facility) N!Q Feet FURNISHED BY CAPCW l0,<- 1 G\ W 0IN C�C� VV � vv V i 1 V 1 6v r J7 n re p, w Q Q O o ?1R� O cam,°� �• ?r r Q s d '� r i 30 -2- Vv / No. ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) AComplete System ❑Individual Components Location Address or Lot No. tj O 1 0 IZ-0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel H y4dpl5 Installer's Name,Address,and Te.No. 3"08-4'1-1 9%1 1 Designer's Name3 Add ess,and Tel.No, CAP&--)+nE S:WJTGa415a$ 1.f C- Cn u S M46161 PEL' 1157s GiEt,?,,fbGxPi> H,�- t4sk,;.c MA Type of Building: Dwelling No.of Bedrooms Lot Size 171 6 aO— sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow(min.required) 3 3 o gpd Design flow provided S30, C gpd Plan Date 5".a® f Number of sheets r Revision Date Title 5-0A'4-'44 S ' 044,� H V - 01.5 Size of Septic Tank t , 000 G4(LOX) Type of S.A.S. (a) 5 oo 64tLOO G(`4((.aa3 S a Description of Soil M j--b i K 5 [ ib, 3 Ll I-3 6 u S 1>4 AJ Nature of Repairs or Alterations(Answer when applicable) 051c— &—W6TwC—, t000 -j Oft ? D -C60Y, Q) (a) :Gz> &"4DAJ z.6)(0-4106 Ca m; uja-til A{{WQ,(- ^Sk AoyL 3li rLxZ 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 Heal Signed Date "010 Application Approved by Date — s Application Disapproved by Date for the following reasons Permit No. 4V e3 U/� Date Issued ._c 1r/ {Qs« 1 No. 302— Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(!l) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 501 0,41- GCA N?> 'C>Vp Owner's Name,Address,and Tel.No. � � S FEDC-DC . N4T(oNA-c, Assessor's Map/Parcel oZ 7 02 5 1 k Installer's Name,Address,and Te.No. 5og.4 %S'7'7 Designer's Name,Address,and Tel.No. C PC-wtAE 61vTt�C8a2�S�$ t.C.e. s %--r6cw-.RA,l R-ESnod✓Sce.(r4-cr S"(' M S�!iPEL' ts R A N t+A&4 MA Type of Building: -. � Dwelling' No.of Bedrooms 3 Lot Size 7((p a O— sq.ft. Garbage Grinder( ) Other Type of Building (� (��).!'q(�Iq-I� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 o gpd, :Design flow proyided gpd Plan Date - Jr' -0a0( Number of sheets f Revision Date Title 5 O A(4LAx)b Ro� HyACIL)AJ fg Size of Septic Tanker c4�C Type of S.A.S.(a) Soo 644.LOO 4,_-A4 G(8a,5 Description of Soil IL►4-7T t c j04d, 3 6`t Nature of Repairs or Alterations(Answer when applicable) AJS� ��k6STl�G lJr�C7 �c -7?TcC. 1�1 —ta _too 'I7) lax) L04rx>bc GN !, cf)('t-� a. P16R T?LA ,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 Healt Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. d� 7 �f U Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of CComptiante TIES IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by C A n Gw roc &I UA rSF-s' L.C. e ' at 5()1 10A K GA06 Pe) �4&&4)( ( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.aal' s--3()�— d ate 7d� Installer 041) GLIbf= E'S' L.� Designer Edo -7�( #bedrooms , Approved desitZon fl .330 gpd The issuance of this 'ermit shall not be construed as a guarantee that the system will as design Date Inspector U� / I pZ 0 5 '?j Cl� r Fees. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS -Misposal *pstem Construction Permit Permission is hereby granted to Construct C ) Repair(�) U/grade( ) Abandon( ) System located at 0 I 0A KLAWb P. V,)Ak)j($' 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 perm' c, Date �-' Approved by I tt ' Town of Barnstable Regulatory Services Richard V. Seali, Interim Director BAANSTABLL MASS. Public Health Division �'preni9.ar" Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i Installer& Designer' Certification Form Date: SC-Ipf�� 01) Sewage Permit# 200l r 3c%Z Assessor's Map\Parcel 2-7z S5 Designer: �1V;6� hOwri Installer: Address: S5 (,d Address; �A C�✓v�✓'- °F_C£1,�� . On L OwA'o was issned,a permit to install a (date) (installer} I i septic system at 1;0 l k I014 based on a design drawn by (address) �,• p Is 2-01 S 1J1Uil�vi ON CIOPw'r dated (designer) \/ I certify that the sel,)tic system reierenct'd above was installed substantially according to the design, which tray include. minor aliproved changes such as lateral. relocation of the distribution box and/or septic tank. Steip out (if requned) Evas, inspected and [lie soils were found satisfactory. i I certify that the septic systeni referetviced above was installed with major changes (i,e. greater than 101 lateral relocation of the'SAS or any vertical relocation of any comgtonent of the septic system) but ire accordance with. State& Local Regulations. Plan revision or certif Qed as-built by designer to follow. Strip out(if rcgtti;red) was inspected and (lie soils were found satisfactui I certii} that the system referenced above was constrtr, iance With. the: terms of the l\A approval Ietters (if applicable) moo" DAVID. m. o COUCHANC1.' R 'Cats Si gat -eNts. 1Q93g , SgN1TATk��'N � ., bC (Designer's Signature ! (Affix �esrgr�er s Stanup lGerc.) PLEASE RETURN TO BARNST.:BLl PUBLIC. HEALTH INVISION. CERTGFIC J'l OF COMPLIANCE WILL NOT 13E IfSSEED UNT[L ROTH THIS FORM AND As- BUILT CARD ARE RECEIVED BY THE BARNSTA.13LE,PUBLIC HEALTH DIVISIOiV. THANK YOU. i };',tiefrtic�Uesicnc r Certification J;onu li,ev 9-14-1 s,doc -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. C -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REGUIREMENTS OF 4LtMASSACHU cIs nqr � CODE SETTS R 15). b SEPTIC (310 CM ELEVATION O -INSTALLER TO VERIFY LOCATIONS OF ALL 6 5.0 0 EXCAVATING FOR SYSTEM. BEFORE `TAP OF -ECO-TECH ENVIRONMENTAL RECOMMENDS III THE INSTALLATION OF LOW FLOW U FIXTURES 3 APPLIANCES. AND t� PERIODIC PUMPING OF THE SEPTIC TANK. 1 fJit�•1 E SYSTEM IS NOT DESIGNED TO WITHSTAND 1 VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 8 -PUMP COLLAPSE 3 FILL EXISTING LEACH PITS. ('� REMOVE ANY CONTAMINATED SOILS IN - ___--- - - VICINITY OF PROPOSED LEACHING AND 64 REPLACE WITH CLEAN SAND PER TITLE 5. /Y cz THIS IS A b4 PAVED DRIVEWA f COLOR PLAN USE COLOR PLAN ONLY 1 FOR INSTALLATION FULL DETAIL IS BEST VIEWED IN FULL COLOR O � 1 cn M >O M SHED o . 1 © o IB I ® '� v l OAK w MINIMAL fl GRADING -� PROPOSED i 2b ft G C' I PROPOSED SOIL 1 ® ABSORPTION 1 SYSTEM I -SEE DETAIL w ® ON BACK _ cn 2 *15 ,n O O OAK j9 ft12 if? ( �� 12 in PINE T LEGEND 1 1 PINE OWED i` SEPTIC COMPONENTS 1 / 64 EXISTINO 1000 GAL SEPTIC TANK LSO 12 UT§L�aTor-S 12 in l EXISTING PINEzkl WATER LINE —0— \O LEACH PIT/ 3 AREA `- 17620 sf+- \��, WATER GATE O CESSPOOL PLAN BOOK206 PAGE 57 OAS LINE DISTRIBUTION BOX ECI ASSR MAP1272 PCL 58 00,.0 TEL/CABLE TVA 1 P n OVERHEAD MRE 0{ - TEST PIT ® -- 1 \ L5 SCALE: 1 in = 20 ft nn 4 0 20. 40 ELFEVA TIONNS • - _ ELEVATIONS SPECIFIED ARE O 10 20 INVERT ELEVATIONS (BOTTOM OF PIPE) EXPRESSED IN DECIMAL FEET PRINT ON. 8-112 x 14 in PAPER SEPTIC TANK OUT 60.93 FOR PROPER SCALE D-BOX IN 60.52 THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM D—BOX OUT 60.35 DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING LEACHING SYSTEM IN 60.30 PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER BOTTOM OF LEACHING 58.30 SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR: �° a Q o o- SEWAGE DISPOSAL Q INC 02 O h ��N DF MASS9`9 �N OF MASS9� V SYSTEM 'PLAN 2 = 2 0 = D D. G� DAVID yGJ -TO SERVE EXISTING DWELLING aD. o k ;3 COUGHANOWR N , COUGHAN( WR FEDERAL NATIONAL 0 2 W m a No. 1093 No. 461 MORTGAGE ASSN. ROUTE 28 J ' J OWNER(S) OF RECORD UTH R AD Gl �FSi ��� qPp ��' ~�\ � �p� Oka FALM s , S, R° ' r % 501 OAKLAND ROAD AW TO 155 Geo Ryder Rd S PROPERTY AS ADDRESS MA [HYANNIS. .MA SCALE Chatham, MA 02633 Davidcou®HotmaiLcom DATE: AUGUST 5. 2015 O C U S M A P 508 364-0894J=j jDe ETE-3944 �0�� TEST �OC� DATE: �771UST 4,D2015 pESIGN CALCULATIONS SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE *461 DESIGN FLOW: 3 BEDROOMS X 110 GPD 330 GPD WITNESSED BY: DAVID STANTON, HEALTH DEPT. = 1` NO GROUNDWATER ENCOUNTERED SEPTIC TANK, 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 PpK AT 64 In - 2 hMNRNCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL ' OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL INCHES ORIZON TEXTURE (MUNSELL) MOTTLES NEW 1500 GALLON SEPTIC TANK. 64.15 0-3 O LOAM 10 YR 2/1 NONE FRIABLE DISTRIBUTION BOX. INSTALL UNIT DEPICTED BELOW. 3-8 A LOAMY SAND 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: 61.15 8-36 B LOAMY SAND 10 YR 5/4 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 36-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 53.15 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. NO TEST PIT 2 MIN/INCHNN CATER ENCOUNTERED THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY I SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH: INCHES HORIZON TEXTURE (MUNSELL) MOTTLES BOTTOM AREA = .(24 x 12.5) = 300 sq. ft. 64.00 0-10 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE _ + + + = 46 sg. ft. 61.17 10-34 Bw SANDY LOAM 10 YR 5/8 NONE FRIABLE TOTAL AREA - 446 sq. ft. 52 52 34-138 C MEDIUM SAND 10 YR 6/4 NONE LOOSE FLOW CAPACITY = 0.74 x 446 = 330.04 gal/day INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED P I BELOW. FLOW CAPACITY = 330.04 galldog WHICH EXCEEDS 1 o G A L L Oo N S E TIC T,A K THE 330 olldoy REQUIRED FOR A THREE BEDROOM DESIGN. amirm r a Monaco 8 MAR TANK TO BE PUMPED DRY AT TIME OF INSTALLATION AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. REPLACE WITH A NEW 1 in R .. IF0CRACKED�ROTTED SOIL ABSORPTION TANK TAPER � OR OTHERWISE SYSTc CC COMPROMISED. M CONSTRUCTION DETAIL USE SHOREY PRECAST SOO GALLON LEACHING DRYWELL c DRYWELL o 00 UNIT 24.0 ft NOT TO cpz SCALE \0 \� � U ® > i v� N 8 ft-6 in A �IL OUT c N � INLET ST ONE LET COVER COVER 3.5 ft 8.5 ft 8.5 ft 3.5 ft IN DROPUFLOW LINE 500 GALLON DRYWELL FROM /0 In - 14 TO DIMENSIONS & DETAIL BUILDING INSTALL ONE INSPECTION +- D-BOX RISER TO WITHIN THREE 48 in INCHES OF FINAL GRADE LIQUID GAS /-I H 50 & INDICATE LOCATION LEVEL BAFFLE UNIT ON AS-BUILT QOp 33 b in .STONE BASE IF NEW ��`D'pl C, �j •! �I� �5�0 in oo>dfi�, 0000>ob� 0000 �pfip0❑io��7 0�� SEPARATION BETWEEN INLET & OUTLET o � 00 TEES NO LESS THAN LIQUID DEPTH CROSS SECTION VIEW 102 M� _ Box � CROSS SECTION VIEW DISTRIBUTION Box X �; � INSTALL AN APPROVED OEOTEXTILE � ;o FABRIC OVER STONE o. om Jo O p 28 3/4 In TO o 24 in e' W4 M TO 12 In 1-V2 in GRAVEL EFFECTIVE° 1-1/2 M GRAVEL in o DEPTH e MIN LO N TANK TO 46 in 58 in 46 in b (q ® o; K SAS 150 in .\O 6 /n STONE BASE 21 i0 7) CROSS SECTION VIEW IF L Oo w TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE ITC BE i 40 PVC 4ST1NG'5*0REi1FER +- 6 In OF FINAL GRADE AND TO PITCH AT 1/8 In/ft MIN 64.05 C-SOX 3' EXISTING USE 61.05 MAX =0 GALLON � PRECAST �$o°SEPTIC TAN60.93 °� °�°��,60.350 °°a°o8 DRYWELL a� �o TO DETAIL BOX STONE SOIL ABSORPTION + 60.52 BASE 60.30 w. EXISTING ° �^ sronie ease iF New SYSTEM -REFER TO o 28 ft 5-12 ft DETAIL BOX 58.30 NO GROUNDWATER BELOW MOTTLING OBSERVED _ 52.50 SEWAGE DISPOSAL SYSTEM PLAN 501 OAKLAND ROAD HYANNIS. MA AUGUST S. 2015 ETE-394 PG 2/2 4., �r Town of Barnstable Barn Regulatory Services Department j • iARNSTASIX •. MASS 1639. Public Health Division 10 m FD1' A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200 0001 0358 3834 Federal Nat'l Mortgage Association PO Box 650043 Dallas, Texas 75265-0043 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 501 Oakland Road,Hyannis, MA 02601,MA was last inspected on 3/30/3015,by Darrell Stone, a certified septic inspector for the State of • Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit with high liquid level, <12" below pit (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF ThE BOARD OF HEALTH �=c ean, R.S., Agent of the Board of Health • Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\501 Oakland Road,Hy Apr 2015.doc • IVv_I V JIM.- I FFFk Commonwealth of Massachusetts f W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i;oW , 501 Oakland Rd Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is Hyannis, MA 02601 3-30-15 required for every page. City/Town State Zip Code Date of Inspection 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 A. General Information I filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 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: ❑ Pa El Conditionally Passes ® Fails ❑ eeds urther Evaluatio he Local pproving Authority 4-2-15 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page, Cityrrown 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: S) 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"hot 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Y i. Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Citylrown 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 orrreplaced ❑ 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' 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �N 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owier Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Citylrown 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.1.00.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: ou st indicate"Yes"or"No"to each of the following for all inspections: ` Yes No ® ElBackup 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 r clogged SAS or cesspool ❑ iquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 uv� &J') Por� d 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 501 Oakland Rd_ Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, -MA 02601 3-30-1-5 page. CityrFown 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 El ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis;performed at a DEP certified laboratory,for 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 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 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 16.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 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 501 Oakland Rd Hyannis MA Property Address Fannie Mae Owner Owner's Name information is H annis MA 02601 3-30-15 required for every y 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? El ® 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 Q available note,as NIA) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? • ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health- ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Na Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling Number of current residents: 0 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 years usage(gpd)): 198.78 GPD Detail: 2014-71,060 gallons 2013-74,052 gallons Sump pump? ❑ Yes ® No Last date of occupancy: last week Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design.flow.(seatslpersonslsq fit.,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-3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owners Name information is required for every. Hyannis, MA 02601 3-30-15 page. Cltyrrown 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: Unknown 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: 0 Septic tank, distribution boz 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 froml 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-3/13 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 501 Oakland Rd_ Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24„+/- feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(Iocate on site.plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years I.s age confirmed by a Certificate of Compliance? (attach a copy of certificate) :❑ Yes :❑ No Dimensions: 1000 gallon Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 ' page. Cityrrown 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 ? Scum thickness 161+ Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? Shovel Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Sludge couldn't be measured due to the extreme high volume of scum Grade to inlet cover 8" Outlet 18" Normal liquid level No sign of leakage Concrete outlet tee The septic tank requires pumping Recommended maintenance pumping every 2-3 years 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-3113 Title 5 Official Inspection Farm: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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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•3/13 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 501 Oakland Rd. Hyannis, MA Property Address P Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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 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.): No d-box encountered Pump Chamber(locate on site plan): Pumps in wotking'olyd`er`' ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 t • � � Lk�� l z2 Commonwealth of Massachusetts Title 5 official Inspection Form _ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is Y required for every Hyannis, MA 02601 3-30-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments_(note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): 1 (5x6')cesspool Grade to cesspool 9" Bottom 104" Ponding 60" Ponding at outlet invert 1 (6x6').pit with stone Grade to pit 39" Cover 29" Bottom 122" Ponding 74" Staining over pit Failed 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owners Name information is Hyannis, MA 02601 3-30-15 required for every y . page. City/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.): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Cityrrown 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 publicwater supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i t O A B zo-& I9-Z 2 /(- 27 3 I Z- S 1 37-6 1 1 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is Hyannis, MA 02601. 3-30-15 required for every, y _ 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:_ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date. ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Depth to ground water was not determined due to the failure of the system Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 J Commonwealth of Massachusetts Titie g Official inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 _- page. Cityrrown 'State -Zip Code bate 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 El Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 501 Oakland Rd. Hyannis, MA Property Address ;X1 Fannie Mae , Owner Owner's Name _ information is required for every Hyannis, MA 02601 3-30-15 'page. Cityrrown State Zip Code Date of Inspection -� co 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 Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 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: ❑ Pas s Ffoving nally Passes ® Fails El N urther Evaluation Authority 4-2-15 In ecto s Signat re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""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.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Cityrrown 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: ❑ 1 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. r *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): r:5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is y required for every H annis, MA 02601 3-30-15 page. Cityrrown 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): I ❑ 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-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is Hyannis, MA 2 1 - - regwred for every y 0 60 3 30 15 page. Cityfrown 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 1/z day flow t5ins-3113 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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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. ❑ ® 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•3/13 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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. City/Town 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? ® ❑ 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): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M se''v 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 198.78 GPD 9 ( y 9 (gP ))� Detail: 2014-71,060 gallons 2013-74,052 gallons Sump pump? ❑ Yes ® No Last date of occupancy: last week 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•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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: Unknown 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•3/13 Tide 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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"+/- feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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 Scum thickness 16 + Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? Shovel Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Sludge couldn't be measured due to the extreme high volume of scum Grade to inlet cover 8" Outlet 18" Normal liquid level No sign of leakage Concrete outlet tee The septic tank requires pumping Recommended maintenance pumping every 2-3 years 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•3/13 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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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•3/13 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 501 Oakland Rd. Hyannis MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 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 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.): No d-box encountered 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: f5ins•3113 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 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1 (5x6') block pit Grade to block pit 9" Bottom 104" Ponding at outlet invert 1 (6x6') pit with stone Grade to pit 39" Cover 29" Bottom 122" Ponding over inlet Failed 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis, MA Property Address Fannie Mae Owner Owner's Name information is MA 02601 3-30-15 required for every Hyannis, page. Cityrrown 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 t r 2 3 I 12- 8 3z- ' 4 36-(/ 34'-$ 5 6 t5ins-3113 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 �., 501 Oakland Rd. Hyannis MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 3-30-15 page. City/Town 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Depth to ground water was not determined due to the failure of the system 1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Y' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 501 Oakland Rd. Hyannis MA Property Address Fannie Mae Owner Owner's Name information is required for every Hyannis, MA 02601 page. CltylTown 3-30-15 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 D-7) Commonwealth of MassachusettsA. - Executive of Environmental Affairs ✓� � 7 � :TM_ DEP ffF Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 5010 alkland Road. Hyannis, M a. Address of O wner: Robert &Judith Kinsey (if different) Date of Inspection: 06/24/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - Mashpee Ma 02649. Tel : (508) 4771420 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 Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s S ignatur�'k� �&- Date: 06124 96 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 501 Oakland Road. Hyannis,M a. Owners : Robert Kinsey Date of Inspection : 06/24/96 INSPECTION SUMMARY: Check A, B,C, or D A)SYSTEM PASSES: XI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) 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 determinate (Y,N, or N D). Describe basis of determination in all instances. If "not determinated",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. ---- 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART A CERTIFICATION (continued) Property Address : 5010 akland R oad. Hyannis, M a. Owner : Robert Kinsey Date of Inspection : 06/24/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING INAMANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption 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 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 analy- sis 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 notrogen 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 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 501 Oakland Road. Hyannis, M a Owner: Robert Kinsey Date of Inspection : 06/24/96 D)SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 501 Oakland Road. Hyannis, M a. Owner: Robert Kinsey Date of Inspection : 06124/96 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 : --- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PART B CHECKLIST Property Address: 5010 akland R oad. Hyannis,M a. Owner: Robert Kinsey Date of Inspection: 06�24196 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. -x The site was inspected for signs of breakout. --x All system components, excluding the Soil Absorption System,have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,'material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 501 Oakland Road. Hyannis, M a. Owner: Robert Kinsey Date of Inspection: 06/24/96 RESIDENTIAL: Design flow : gallons Number of bedrooms Number of current residents: o Z- Garbage grinder (yes or no) : tiv Laundry connected to system (yes or no): cj� Seasonal use (yes or no) :io Water meter readings, if available: Last date of occupancy : COMMERCIALANDUSTRIAL : 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 PJ_tM PI N G RECORDS and source of information : ...A�).U`t ..................... System pumped as part of inspection(yes or no):....N.0........ if yes, volume pumped: .................... gallons Reasonfor pumping:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 501 Oakland Road. Hyannis, Ma. Owner: Robert Kinsey Date of inspection: 06/24/96 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) 1c � �..�� �-�—..1.� �t..:............................ APO? IMATE AGE of all cam�jon ` enks, date installed (if known) and source of information — 5,,..................................................... . ................................................................................................................................................ . ................................ Sewage odors detected when arriving at the site : (yes or no)...t`?CD... SEPTIC TANK : ...uz�;.. (locate on site plan) Depth below grade: ....a.. Material of construction: ...':.. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: Sludge depth:...=.......... Distance from top of sludge to bottom of outlet tee or baffle:......:2................... 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 :.....l.G.................. 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.).............:........ —k-0. ... ::': :ti: ` �.� .e..1—c...y SU�Z rj A e ti ... ............s ....... ................ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 501 Oakland Road. Hyannis,M a. Owner: Robert Kinsey Date of inspection: 06/24/96 GREASE TRAP : .....N!;�..... (locate on site plan) Depth below grade: .... rade: .... Material of construction: .........concrete.........metal........FRP........other(explain).... ................................................................. . Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom 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.)........................ ................................................................................................................................................ ................................................................................................................................................ i TIGHT OR HOLDING TANKS:.... �� ... (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: 501 Oakland Road. Hyannis, M a. Owner: Robert Kinsey Date of inspection: 06/24/96 DISTRIBUTION BOX:..t (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into orout of box, etc.).................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ PUMP CHAMBER:....P.O.. (locate on the site) Pumps in working order: [yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ 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: ...P-1 v leaching chambers,number:........ leaching galleries, number:........... leaching trenches, number ,length:..................... leaching fields, number, dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, etc.). {{1 11(: �YCGYti /�>> :��1 � ...�. t ..:.... ... .. _: ...... .?...�:` ,�`Y................. .. .3................ ............ .... �D SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property address: 507 Oakland Road. Hyannis, Ma. Owner: Robert Kinsey Date of inspection: 06/24/96 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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ PR IVY : ...00..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ ................................................................................................................................................ I SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 501 Oakland Road. Hyannis, Ma. Owner: Robert Kinsey Date of inspection: .06/24/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. j ?13 I DEPTH TO GROUNDWATER: Depth to groundwater: .� .feet Method of determination or approximative: .UdS..Q�.�a�tY•.�c.;,::�''-,....5..)cz;Cv�;;; `,c-�.;�.4:^::r?:1:.....1.1....'l`.::.��:.�`xa .... ........ .......... -, /l l l hp 4 * e \. l.7rt P (St l .� -t- .,:.3...........:.....Y:....... ................ ....�.......6 A................rc..... :.... ...... ..:rr..... ......... :: :....�....C�. ........................................................................................................ ............ L � LOCATIONS SEWAGE PERMIT NO. 45 C L c VILLAGE A & E CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER t DATE PERMIT ISSUED C DATE COMPLIANCE ISSUED a 4+ �_ ' 9� µ �� • a� O n � .f /_"ti,\• I t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I! �� Town Barnstable OF F.............................................. Appliration for Uiipusal Wjark,5 Tnnitrnr#tnn erntit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 501 Oakland Road, Hyannis, MA 02601 .................................................................................................. -••--......_._...---•--..........--•••--------•--•..._.....................----•-................. Robert Kinsey Location•Address 501 Oakland Road, cfty nis, MA 02601 W A & B Cesspool Serv�7der 128 Bishops Terrace, nnis MA 02601 -- -------••..............................•----•-••----....................-•--......._.....--•... ....--••-•....-•--•---........._......••--._.:........................................-•-•--...-- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......................3 ..................... Attic j ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Pa Other fixtures ......................••-•-----• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 14 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water................... Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water....................... R: •----------------•--•--•--•...------........----.............................................................................................................. 0 Description of Soil........SaP................ x U -------•---------•••-- •--•-•---•.........................•--•••-----------•----...------....._..------------------------....---...-----•-----................•---------------------•----------------••- W •----------•-----------•-•---•---•--•--------------•--------•-----••••---•-•-•-••--••••-•-..._._..--------•--------------•-----••--------•-•--------•----••-•------------•----------..__..._..... UNature of Repairs or Alterations—Answer when applicable.installation•-•of a.-11000 gallon-,---stone ._ Wickedleach Pit...�Overflow�'-------------••---.....•-•--•--......--•....••-•- . • --- ----••••••--•-••---•-•--•------------•-........•---......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLE 5 of the State Sanitary Code—The undersigned f r grees not to place the system in operation until a Certificate of Compliance has ben ' `sued by the Signed _ .._... .-•----..........-- 11.42<..... -••2�06�84 / Dom, ApplicationApproved By................................----------- --------------------------------------- -•---------21._06!.'`.............. Date Application Disapproved for the following reasons:---•--...---•..............•--••-----------.............---......--••-------..........-------•••------....--•- -----------------•--........--------•----•--•----------•-----------------••-----•-..................•••----.....-•-......-••-------•--------••-•...-•-••••••-•--•-••••••...---•.......--•.....--•••-•--- Date PermitNo.....-84• -••-•------•..............•-•-•--•-•••••--- Issued.•..? 06/............................................. Date No.,84-111 FEs.. ..:15.00....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town .......-..oF.........Barnstable . .. - -------------------------------------••-------.. AVV ira ivu for Ui iVwi l Workii Tomitror#'ion thrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 501 Oakland Road, Hyannis, IA 02601 ---------------------•-----..................................................................... -•--....-•-•-••----...••-----•--•------•------•-------•-.....-----•..........._.............------ Robert Kinsey Location-Address 501 Oakland Road, 'Ayannis, n 02601 ......................-.......................................................................... •.......-•••-••......----.....-•----...........__.....---.._..•---•-- .........._.........:...... W A & B Cesspool Serv�'cer 12P Bishops Terrac4dd annis , YA, 02601 Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.................___3 .....................Expansion Attic( ) Garbage Grinder ( ) pa Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures .................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............._. Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________ _______ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-...................... ----••••-•••--------------•••--••••••-•••-•---•--•...•-•••--•-••-•••--•.............._....._._....••......................................................... 0 Description of Soil.......Wd••••-•-•- •••-•••---•-•••••---•••••...... U -----------------------•---------------._...---•--...-•--------•---------------------•-•-•-----•----.......-•------------------------------------------••-•- W --- ----------- ------------------------------•------------ ....................•••••••-•-•---•••-•---•--•--•••••-•------•-------•••--•••--•••••-•-••-•--•-•••••-•••---••-•••......................... M. Nature of Repairs or Alterations—Answer when applicable_j j��#1lation of a 1,000 gallon} stone .lacked__leach-.s.t_•(Overflaw) . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL L 5 of the State Sanitary Code—The undersigneffuwr grees not to place the system in operation until a Certificate of Compliance has been sued bythe b r 84 Signed_;�`f�, _'/ � -•--..... •-- --••_�r_�---•- ..........................06� _.... ApplicationApproved By................................................................................................ ........... �o6 ............. Date Application Disapproved for the following reasons-------------------=-------------•--------•--•-----------------...----------------••-•-•••-...---------........_ ------------------------------------•-------•--------------------•--------------.._..._...--•--•---....---•----••-•---•-••••••••-••••-•••-•-•••-••••-•-•-•---•--••-•--....-••-•-•---••••..._---•--....._ Date Permit No...... ��--� -------------------------------•------•---.. Issued -2�06�8�---•---•--...._.. ------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............::.....I'�n............OF..............Barnst....able... . ............................................. Tntif irate of TomViianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) by..A & B Cesspool Service, 128 Bishops Terrace, Hyannis, PEA 02601 ---•-------------------------•---••-•...._.._•---•-•- Instal at......... 01 Oakland Rd.'--tlyannas , MA---••02601 --------obert Kinse-y................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary CQdgO�s/scribed in the application for Disposal Works Construction Permit No......................................... dated_......__..__...___.___.__._..................... THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WIL �F ION SATISFACTORY. DATE._.../. : Inspector ... 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T own..........OF.•••--••-Barnstable -------------------•-•-••-••---••...._............ 5 -00 No............... ...1 FEE........................ ikgoiial Workii Tonotrudion anti# A & B Cesspool Service Permission as hereby granted --------- ----------------•--••-----•-- --------- to Construe ((� )) or Re air (X ) an Individual Se T e Disposal System 01 Oakland Rd., Hyannis , CIA 0`��1 - Robert Kinsey atNo.. ----•--•-••- •---- • .........................• ... y Street as shown on the applica 'on for Disposal Works Construction Permit NoW ated_���?&'________________________ .......................... ealth DATE " .-----••••-•-•-•••--- FORM 1255 A. M. SULKIN, INC., BOSTON