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0514 OAKLAND ROAD - Health
514 Oakland Rd 272-060 Hyannis i c } TOWN OF A.RNSTABLE L; � ATI004�; I Y VkOD SEWAGE # .I`►(J VILLAGE VVA/I S ASSESSORA M & LOT �72'D(o© AP INSTALLER'S NAME&PHONE NO. GGc✓ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �I°�' ✓�" '� (size) 3b�����Y` NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: v 3 COMPLIANCE DATE: y 3 , `Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � V V v v U i ® a F V /NSPeCTiorJ r TOWN OF BARNSTABLE ely�s5g'-D ,G CATION S/y �� ��^a SEWAGE # VELLA ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= G�-S moo LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � J �J � � d � S ?- 0 1 � � � � L.. �. M !SR No. �0 477 O . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Bispo8al 6pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. O� �l'' Z�e-e Owner's Name,Address,and Tel.No. /may _ Assessor's Map/Parcel —1 7-L `®1t41® 2t) 4gF-Z,4-AFr Installer's Name,Address,and Tel.No. Designer's Nam Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size ft. Garbage Grinder( ) Other Type of Building G�6T'� c No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow pro ded gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank e of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Gt�G��.dC� .� "B�®X /J�°/.�e,0Z 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 a lth. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� d� Date Issued No. �O I`-7- O � j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Mispoeal 6pstrin Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System A Individual Components Location Address or Lot No. Off' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel � 7'�► Installer's Name,Address,and Tel.No. Designer's Name Address,and Tel.No. , Type of Building: ` Dwelling No.of Bedrooms ? Lot Size ft. Garbage Grinder( ) Other Type of Building ��`� No.of Persons Showers( ) Cafeteria( ) Other Fixtures ; Design Flow(min.required) gpd Design flow pro ded gpd / Plan Date Number of sheets Revision Date Title Size of Septic Tank I pe of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of e lth. /P Signed Date Application Approved by C��C -'7 cam_ S Date Application Disapproved by Date for the following reasons Permit No. ao 1-7- 050 Date Issued 3 ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by V .G G�BO�v✓'�` --r ®/��'� `�v at ��� OA/�'�jq/y b .b /T✓ has been con cted ii acc/o)r with the provisions of Title 5 and the for Disposal System Construction Permit No. / �V...da`t�d Installer //J7 �G�l��c��✓/�' Designer #bedrooms 3 Approved esign flow gpd The issuance of is pe it shall not be construed as a guarantee that the system will fu ction as d s' ned. Date 3 ( Inspector ✓ �� ----------------------hh-------------------------------------- --------- = = _----_ -------- --------------�` No.�O 7-V 5(6 Fee -7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal *pstrm (Construction 3permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at �.� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons uc ion must be completed within three years of the date of this permit.r," Date -3 Approved by AsBuilt Page 1 of 1 (� VTOWN OF ARNSTABLE U TI L' ON I r 1� SEWAGE N VILLAGE ASSESSOR A MAP&LOT 292—o60 INSTALLER'S NAME&PHONE NO. G✓ SEPTIC TANK CAPACITY SOv d ✓r_ LEACHING FACILITY:(type) •��W (site) Y1� NO.OF BEDROOMS � BUILDER OR OWNER PERMITDATE: 3 COMPLIANCE DATE: N 9 0 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist an site or within 200 feet of leaching facility) Feet • Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,clk.�yry J J �i�$T'��Gfaue+rS 45 ace, ys, http://issgl2/intranet/propdata/prebuilt.aspx?mappar=272060&seq=1 3/8/2017 r Commonwealth of Massachusetts a:702^0&0 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoPunta_ry Assessments 514 Oakland Road, Hyannis Property Address W Alfred Bleu _ Owner Owner's Name information is ss required for every MawAetfs-mills MA 02648 March 8, 2017 page. City/Town 6rState Zip Code Date of Inspection A tR� 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 filling out forms S I? (p �— on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. Company Name 4 Glacier Path Company Address East Sandwich MA 02537 Cityrrown State Zip Code 508-833-2177 s1287 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority March 8, 2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 VS w Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 514 Oakland Road Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The information contained in this report represents the condition of the system for a moment in time on March 8, 2017 and does not represent or guarantee the condition or the operation of the system from this point forward. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts U W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. City/Town 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 '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. Cityfrown 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 oir less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes' or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes'to any question in Section E the system is considered a significant threat, or answered "yes' in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Yes 9 ( y 9 (gP ))� Detail: Per Hyannis Water Department; 2016; 120,000 gallons and 2015; 88,500 gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. City/Town 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: Barnstable Board of Health Was system pumped as part of the inspection? ❑ Yes ® No 'if yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 4/9/2003 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: 10'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 19"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) Tank is a poly tank with risers within 6 inches of grade on the inlet. There is no riser on the outlet. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1500 i 4" Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 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 38" Scum thickness 2" 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 12 How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is 19 inches below grade with a riser on the inlet within 6 inches of grade. There is no outlet riser. Tank is Poly. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is Marstons Mills MA 02648 March 8 2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 . page. Citylrown 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 level with outlet inverts 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.): Distribution box was recently replaced with an H2O dbox due to the decayed condition. Dbox is 25 inches below grade with riser within 6 inches. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is Marstons Mills MA 02648 March 8, 2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 Hi Cap Infiltrators ❑ 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.): No inspection port on the infiltrators. Probed the area without any indication of standing effluent or wet soil. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8 2017 page. CityrTown 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: 20feet Please indicate all methods used to determine the high groundwater 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: Groundwater Contour Map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Utilized the Town of Barnstable Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 514 Oakland Road, Hyannis Property Address Alfred Bleu Owner Owner's Name information is required for every Marstons Mills MA 02648 March 8, 2017 page. CityrFown 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 i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 C� TOWN OF ARNSTABLE LOCH ION / AA" SEWAGE R VILLAGE f n n )S -ASSESSOR: MAp&LOT 292-060 INSTALLER'S NAME bt PHONE NO. c.✓ SEPTIC TANK CAPACITY SOU d ✓K- LEACHING FACI.M:(type) NO.OF BEDROOMS � BULDEROROWNER ✓' b PERMTTDATE: 113 COMPLIANCE DATE.: . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist _ on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(if any wetlands exist within 301)feet of leaching facility) Feet Futnisbed by i J m o S�r`TpaIC_. -�z 6i/57'�ELCaverS a�. Bar http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=272060&seq=1 3/9/2017 No. 3 /LJ O FEE COMMONWEA LT14 ®f MASSACHUS ETTS Board of Health, S-MA N E ,MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) -XComplete System ❑Individual Components Location 514N Owner's Name 1 ' Map/Parcel# Z. Address S y- QA A hTN�5 Lot# Telephone# Installer's Name C ` Designer's Name V 1 Address Yc Addressi. µA Telephone# (DLL — 5 (� Telephone# SLR .p�9(p53b Type of Building 8� �� Lot Size I�J.Z g� sq.ft. Dwelling-No.of Bedrooms �A_W Garbage grinder.W/A Other-Type of Building N ChyE No.of persons _Showers ( Cafeteria (✓f Other Fixtures L.Au Q-ra7_q k,a cwe t4 StQk. L A%;o 0_9w Design Flow(min.required) 33 gpd Calculated design flow 0 Design flow provided . 4,4g gpd Plan: Date 4r1�� n 1)1� Number of sheets ( Revision Date Title et c aOOo f-:F '}�C c571_&4x-n Description of Soil(s) t Rio �e2� A '7//�Cr, •1 �+ Soil Evaluator Form No. £ Name of Soil Evaluator LZM(sn1 tJNflV.Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS —\KQ Q�(0,67*6 !;=QM C\ CA V-1 7j r_NVI- r-r_n AAA or—'r r1t••-.—^.�,. L►_t i EaN AND CERTIP! `NI t.. r!',3TL00 WAS INSTALLED e The un ersigned agrees to install the above described Individual Sewage Disposal System in accordancewi#U-they,prro,� isions of TITLE 5 and further a es=Ottoe tem' o ration until a Certificate o ' omp'anc has been issued by the Board of Health. Signed n Date Inspections .._+._..-...",".-,...a+..-�'.-.,,..-li_�..�r_ .'�..`�..r..,.t�...`.�....-.,.%�.a.--"`"'"''��.� ,/'�."^'�`�"r`*.r'K�'r•-at a,.+I`t"'°.:.,-.�.`w"'rr�e+��"-[Y�.tsf';,.,.^._-,ra"'.—�1.r-,,,r..r-.......'.w..:`.,.-'•.. --'..— .-1 :� 3 -/y0 o No. ��� A•� I. FEE ..� l Board of Health, ��H�.tJ ST r\`r3t_E MA. APPLICATION FOR,DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repai)< Upgrade( ) Abandon(�4'`;,Complete System ❑Individual Components V Location 5 H Owner's Name TN%C�CS WlapfParcel# �-')'7 Z' 1P���� ��p Address 514 ��KLA O }fi C��tJN15 i v Lot# ,4 Telephone# Installer's Name �A S �CpT1C SE jv C£ Designer's Name S�F1J ��U!�'Gf>C114.(1Ac.`rsiCS Address Mgt l l ��• TC,C�C�i�(�t� n Address' lo -� `Lri,(`o)�;v'Q(1 M� Telephone# Uy Lq - 5 3N v Telephone# j48-Q-j✓(o rJ*S(-, Type of Building Lot Size (J!Z 9Q sq.ft. Dwelling,-No.of,,Bedrooms " 'CSC �'$Q 2 Garbage grinder 1'X�,..•,. Other-Type of Building N ON\E No.of persons `J Showers (►`rCafeteria e✓ y. .;,.. f ~~Other Fixtures °,. L-Xlvl ta^cZ:: q "T f<\E Design Flow('rain.required) gpd Calculated design flow 3 30 Design flow provided 33 4 4$ gpd Plan: Date 4 ' ^-{�O Number roof sheets I Revision Date Title T�OG�>oSsQe\ c-)eo-3,\C Su1S4r-,, QPc\M&P ,� ' Description ofSoil(s) \C(-" Soil Evaluator Form No. Name of Soil Evaluator CAZ 1EfJ S10 V Date of Evaluation 4 �7 x DESCRIPTION OF REPAIRS OR ALTERATIONS • The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with-die provisions of TITLE 5 and further akr es to 'ot t��o p ce/fhe tern in o ration until a Certificate of Compliance, has been iissued~by the Board of Health. Signed �G �O�il� i/� _ Date �7`/ C, Inspections a y No. �� ® ®1V V�v ®�` �� 1tlJ� �ll� FEE 5 Board of Health / / l�Lf✓lC� 1VIA: CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) Complete System The undersigned here certify that t.e Se ge Dis osal y tem; Constructed ( ),Repaired ( ),Upgraded Abandoned ( by: _ I /,s /L It.�na lI `Z t l 4 5 at 12 l�L nx_ /C has been installed in accordance with the prpvisrpns of 310 CMR 15.00 (Title 5) and t e approved design plans/as-built plans relating to application No. 6",'N -1/yU date/d 4 17 /b 3 Approved Des-ign Flow _ (gpd) Installer Designer: V Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 3�l �U FEE - Board of Health, ,� // !/t MA. f, DISPOSAL SYSTEM STEM CONSTRUCTIONPERMIT Permission's hereby granted t stru t( ) epair( ) Upgrade) Abandon( ) an individual sewage disposal system f �711at / r� [� �C� as described in the application for Disposal System Construction Permit No. off' /YU ), dated ( � IC 3 Provided: Construction shall be completed within three years of the date--of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 9 h )G 3 Board of Health Sip - 20-01 13 : 52 BARNSTABLE HEALTH OEPT 5087906304 r • uc I I 'NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AiXD SOIL EVALUATION EXEMPTION FORM A2ME,•1 �NA`� hereby certify that the engineered plan signed by r e cateC �p 3 concerning the property located at _A�.-01, 1 � A�.10�T_��y�nn�S meets all of the U Ict`.ow;no c- teria. • This failed system is connected to a residential dwelling only. There are no .ornrierzial or business uses associated with the dwelling. • T'.e soil is ciasst`ed as CLASS I and the percolation rate is less than or equal to r?. 11t.`$ per :nch. The applicant may use historical data to conclude this fac: or may �_onduct pre:trr,r,ary tests at the site without a health agent present. • There :s no increase .in flow and/or change, in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen :1,; loot aonve the maximum adjusted groundwater table elevation. fAdiust the ,,%ndwater tattle using the FHmptor method when applicable) Please complete the following: of Grounc+ Surface E!zvation (using GIS information) _ LO STOd g; t�.Vy' E!cvat:or, _ ad;ustment forinigh G.W.¢q._ BETWEEN r\ and B � S.r;' D -- D ATE: 4 NOTICE 33sec j,Orn t�.e atone information, a repair permit will be issued for cedr^ems -a=.imum. :cdittansl bedrooms are authofted to (h future without en,tneerec i:ept,_ system plans. - ).-iln:r,:0u PCICC.%m9 �i Permit Number: ,• Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: L5 14 cOR KLAh10 ARA. . 41.4c 1r1i\5 � MA Lot No. Owner: ?!,Ncmcgr� CC�+C�pc--�- Address: f-)M I Contractor:���`Q �n�lt��c�nn4[1�G�.Address:a= F•IFGAIN( Odic \, Mh 01263(11 Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date o't O 30 month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A�� OA Appropriate index well.................................................... Z o OB Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to � I �, water level for index well ........................... 01. ' • 3 mont /year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ............................................................................................ STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .................................................. .............................. ........................... Figure 13.—Reproducible computation form. 15 An ,Yj � p '�^ '°• ei "MAP, °' x�."..•i" 'yyr °,rr d$. a }<#. � .r.:a i. a -,t. t CARMEN ` y ' { r � � 508 548-0796; , I ak - arr:3.._•�f'Sgr.*lL,tl,, i,.sY�w�;A Fir -o.�t3al� � .�*'�•�i�?' _ � `m�.:"� zr.�.i7y�-«.af.d, '' �^�`°� ENVIRONMENTAL SERVICLSINC "� P O.B0xM627;East:Fai�lmouth,MA 02536` * � „ �4 {n w� ,C�'.a.jy�� 'a�' :�555 t .��g�6,x�7• S >�{��s�� ; 'fix ` r - - � f,.i..r'{`�•�i 7rrr;�.: ti��' ..q-�. ...�.?S�� - ��'k o-:;i� � fi ,Mc.' .�3. jrj�s ._51 ,N - ', 3ty M a+ s3k ar` µ `�Ssr,.k A,, ss' '-�Y "f'�# •saTrt. r t �as3 , 4t Apr119�42003c';� `�}� rs'KFnrp ,,, - 'sT".: D ?,...• rr: " `• '�' srtW, k:i' '.- yt m�'" �1:.. . ,r `- "*# r RE Certification of TIt1e Abeptici ystem Installation _,$"kt jt � Residential Proner}�7-524Oa1cland.Road H anms g t `' `J 6 )� y )1 {',, aM�`•�'"F 3 Js. +✓f,,. � a r` yr` .n ,tt ., r [:�ztr• F�( .�- rR +rt` '! •` xs�.l,, �,y A ' ;:! .a ` .. l V z r- .t, 't a -.7 ac.n _�f t 4 z )"N ti•y-` 5`s".S +. 'r $$ Dear Sir or Madam:.. ,,. t ,r , �.. {r� t ,�t,i x t t y � a �z ., -¢.s "Air.,, t 9 •c EkF� C lea a 1vI,�� ,� - r-"��. � # r .a ?.h ,yy£ On April 8, 2003;Roger Roberts,-Inc wastlssued a p rt_toJnst�all a Title U SePLA; stemrat 524 Oakland Road,-HyaHis, MA; base�dl o'design,txdrawn by Shay'Environmental Services dated; ray t, 4 F z a z,i Ju:fu y: rr b• 'r Fr April 2003. A1 Y 1 p s . � n 4 t.� V # 9,e -x t,ail tr n 1� tx � a� Safii f ti�""� sf yl a Ol � I rj , . ,� ¢ r . i t ,k z ,r � Gxk 1 r a 3 4 k F s 7 a^ at 4 . 'yr t' � u " �� x� i^, XX I Certify That The SepticiSystem,Referenced�Was!Iii fled Substantially According to the Plan di '4 sr f o atC sr i, q � s •."N .. M ( e iA r.wy a:r i0x, ' .tom : a c•t�+ a f �� Rwa � zar""� ja at .< � �: f it S! uw wi"�Ys trY k ^ 2 yi I Certl That the Referenced iAb.ovek Se ticSystem�WasInstalled With@ Changesfbut in .t Accordance With°State and Local R( dations,`�Revlslons or As Built Plans/Sketch will Follow r a-.' x x-}• s �� k�r :t���m, u }. 4 �s. i �.�.a# s, '. The Septic System Was`Not Iistalled�Per a and LocalrRegulatlons°and Corrective Action Is} k _. a f• w., t.•.. s,g, s �".a 7 'i•It» •v"a f.�J� "r 't,M.. Required :IY{ �" drJ ¢tt 41f4 ti.} r y1,ii x ram'sK (1 h a k �p"vt� a.4Z �ip`'� ���M #""� `9.,Fe'L '}, 4 ,t[' #r x'[ { s {,� ,Yt -1�{ f � ,!c. •� i `+;i" „ 33 q ,,TE `. r .. ` i,• - T •a,'.} M,S'i } '!et„{SVN"Mt 1°-' t,SC k � If you have questions pleasedo•not�hesltate tocall theunderslgned'at(508) 0796' any ' 548? F *� Sincerel11 y G �'. -# .73*y+'f 1 d M#x.;43 ��"" Ln t cgs e k s`ra�c• >. ^w ,#s .� r t�' { a x :di'n * .. ! r Yys�4� i"-,s¢7 p `Tr'nn' t;" }x, ^`d 3�s t N - { xi• { S 7� 'J fi ryZ r CARMEN E. SHAY - „3 t° •a z}�" 3:. ; ,... ,s j t '- > , r t ° '!'" •3.y,�1!7^ z �r ti' I Na,: 4!r ENVIRONMENTAL SERVICE �{ ��� � ^tw7sciK �� �F.t. . . .. .. � r .t 4+ �.:��y��` '� y, 'sN�' :�:�'� �ij�'.yr.:�,a'�g- � ' *t�.s'<s g�.t,t.,r '�� 4• n .fit`k i . # �. a -y.c .b,. h� dSA :C� —y t T { CiARNIN �a a `� r 'rry tG+ h ; Qr styt r a d.rpy }'a , ' �'• T�;..I, t 1I^ N .N SI> >�'"t4a"�� v tv� 4: •- �°- r`r,9,5 �- '"_"�n$7r h, 4* ,$... Yz �- �Y'`�' �a'„ •°e T {Z q 4: q,t 1181� t 1. C en E. y R.S C S: �,a President ' t�. ryrt°S .7"+ a:s # �' .#fu +. �J' ,. , r,�,. .AA�.3;,p f• °#-' n { y 1 6,fs :' +k�vX#.s ,}p� `c�` v,�T'r grx�'g,. "XK.r. t2{v'c,r'+da1.A Cer SP`'ay� t:: V4 t 2� +i' x� � i �t ..7 ems: •. sy th .t `r r �'j+ "r '� • f } 1. 3T i �t. ' a i F.'i -. - { i 1" �'� '�-k A.Y'ht i.°r�hpAlh4 a'I � �. `+q+•R. .mil"¢ �}, a t f Z - � I� z d .Ec t• Y �.y � ;,�'r�� '��k ��'u ' �Z��r� ,. 'T $�' sc ✓�•.tn4 eg ��d -S. xl�i �' ..� t .Fk� y� 'G'-. .+�Y, 1M1 !F y r v r s t£ A"a a.a•.73 t. ''+ t �•� :'•`•gx u ""�'' s r `.s rc tlF. ` it.l4�td v§�.; .. .. �• � t,::3 �f:/:5f,•,�k� i�'3��r,� !'Tl�a��� {�., #r ,..:'{syiiC��,#li r�q's •�•` ,e,�t ��'"� •.�d.S �� . n{ �, � � 1 fi°'� l t �' - �° I r } ,•� f„; �Y rs-....I��'� „� �J�" �,, ait+`; �`='HF �`+'�'.�� v4 2,�.d`s'�,�.�.t jam .>td f:.{` 6 ] y�.a-.rl k� , •# ��'i h , .t 9: 7 1 = a f 7'i�t "•,5 .. ak''' :.wl'�'7l M`,�..� 1 t`r i��' i rp.., ! sgr,�', !`� a ,� 'fir# 1 TOWN OF ARNSTABLE LOCATIONAXkf--* SEWAGE # VILLAGE �,q--'aV f S ASSESSO MAP & LOT �1 1,—C-po O INSTALLER'S NAME&PHONE NO. G'° r y SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �1• (size) b KM Y`� NO. OF BEDROOMS l BUILDER OR OWNER PERMITDATE: 3 COMPLIANCE DATE: U 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet j Furnished by 3ka lv/5�'��LCocre�S MRVP # Assessors Office (1st Floor) Assessor /s Map and Parcel # ® ` ,/ Building De artment (4th Floor) Zoning - INSPECTION FEE $ 0.00. RE-INSPECTION FEE $15.00 Request For A Housing Inspection For Certification Under the MA Rental Voucher Program Your Name �1Ssa 14- 6 &_r- Affiliation (Circle One) Owner Rel Estate Agent Tenant Your Address &42M�&01, ,1 Telephone Number (Daj� - (Night) a - 7/ �Q w Address of Property Where Inspection is equested Unit/Apt.# 6Al 0ail t2w, 14tja.d4 " Name of Owner 44tet9 Address Mailing Address (if different) Telephone Number (Day) - d� (Night) z1-�� 7 Will there be any children under the age of six (6) who will be occupying the rental unit? (circle one) Yes 0 Was the dwelling constructed prior to 1979?C es 1 No ------------------------------------------------------------ FOR OFFICE USE ONLY: Certification The dwelling, dwellin unit, or rooming unit located at / VC, (,Z a Cv.�.v was inspected on /®_ZZ/-Zero y tz, Mae -1 to de, S, Health Inspector for the Town of Barnstable and was found to be in compliance with the provisions contained within 105 CMR 410.00, State Sanitary Code II: Minimum Standards of Fitness for Human Habitation. However, this certification does not include a determination as to whether this unit contains any lead paint because under 760 CMR 49.02 Massachusetts Rental Voucher Program, a separate lead paint inspection must be conducted. r Inspector's Signature Date 2 6 FRM30 Caw HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN o DEPARTMENT r c, o ADDRESS yc L U M SVeyw /f 6� —�V / L ' TELEPHONE / Address S Q,I�/�019 /'7'ya '�S Occupant-1� Floor Apartment No. No. of Occupants Z No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming urnts No.Stories Z Name and address of owner 1<a- -?, Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ok ❑ B ❑ F ❑ M Doors,Windows: Lk Roof Gutters, Drains: ok Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: ©V, Dampness: 4," Stairs: o k.. Lighting: STRUCTURE INT. Hall,Stairway: Obst'n. Hall, Floor,Wall,Ceiling: Hall Li htin : Hall Windows: HEATING Chimneys: Central ❑ N Equip. Repair TYPE: FhV Stacks, Flues,Vents: PLUMBING: Supply Line: ►. 1✓� ❑ MS LIST ❑ P Waste Line: _ H.W.Tanks Safety and Vents ov, ELECTRICAL Panels, Meters,Cir.: o k C r c t 1fv"KA - ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box.- Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup. Ten., a , Oil, Elect.: l Z ®/e r�h o� Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove v L/,-�� Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: v !/ VAC Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: Y e� General Building Posted -� Locks on Doors: di-C ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIE F PERJU ol INSPECTOR TITLE lvU_ All DATE t yl Z TIME Z - p A.M. THE NEXT SCHEDULED REINSPECTION P.M. K :.gyp>r.s2r^'q3# 'awk�yy:i�u ::'.xnwGriarirp'.s'�rrxr rr a tg�°'!� t�Wi�F7./re. �y K' wl.t' s PIK 'a 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore.is nof.included in this listing. Failure to include shall in no way be construed as a'determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven . or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. s� � r..(�yy+,:s'";�,{1t`p.r..=:,.,...,y.;-_ f....z..- «: _;.-:d-, i - ,_Y i,.�.... �-.%"Y.y, S;1c'.�•nr�.�^"`�.. �;.t"`,.s',."Z'"`��n`�`--,T".::��,. . r+.a�•ti •.✓.,r..,,•.°w.'•' .,..±-ti._ .-.s-. ,,�5., .. J ' 4M30 H&W HOBBs&WARREN m THE COMMONWEALTH OF MASSACHUSETTS ,. C` BOARD OF HEALTH CITY/TOWN VP o DEPARTMENT y ,Qox say 1G7-rilaw, s�` , y ►k*w ADDRESS VVV�V{6. � L U GSM /T SVey ' l TELEPHONE Address S k�Gw��s��/' y� N 3 Occupant_lisc, Floor Apartment No. _— No.of Occupants Z- NQ.-'of Habitable Rooms No.Sleeping Rooms J— No. dwelling or rooming units _ No. Stories __ Z Name and address of owner Kayeµ 0V,e ,`�N ' Remarks Reg. Vio. -YARD Out Bld s.: Fences: Garbage and Rubbish M j_ (0AA Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: IjL,, Dual Egress: and Obst'n.: Ok ❑ B ❑ F ❑ M Doors,Windows: �_C✓ Roof „LojfA Gutters, Drains: Ol,r. Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: O Dampness: .li v Stairs: O k Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: (� f Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING > Chimneys: Central N4 ❑ N E ui . Repair TYPE: FM Stacks, Flues,Vents: PLUMBING: Supply Line: vt. I Wx IXA ❑ MS ❑ ST ❑ P Waste Line: T'((A- r- H.W.Tanks Safety and Vents OLI, ELECTRICAL Panels, Meters,Cir.: 0k C( Cvi•� gjvoa j&,--- ❑ 110 ❑ 220 Fusing, Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1) Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,rist,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink -Z- (30 Stove (,C�S Clot, Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: v,P f do,I,,, Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: ,t/o Egress Dual and Obst'n: e� General Building Posted �4 Locks on Doors: OTC ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES,OF PERJU�R INSPECTOR TITLE DATE ' l 2 �/ TIME Z• 1 t7 -- A.M. THE NEXT SCHEDULED REINSPECTION P.M. o I J.. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor�shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. _ I", (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing.dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. 0 TROY WILLIAMS �. SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection _ v'p, ���i;.08 760-1819 40 Old Bass River Road .� South Dennis,MA 02660 y'4 Commonweofth of Massachusetts O py Executive Office of Environmental Affairs Department of P Environmental Protection William F.Weld Trudy Coss Cowm« Arpeo Paul Cslluccl u cov.mo« David B.Struhs Cortvnhabner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION / Property Address: S,14/ d a k G RA• "r u~ S Address of Owner. s h ✓ ¢ y r O1' 1"n 14 G Date of Inspection: 8/aZ 0 (If different) / Name of Impector�yp yy (�.) , s (,J �s f Sr Company Name,Address afid Telephone Number. Sec ./�6°."'. 6,7,7 63 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Y Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: /1 /� Date: GtJ /D? p The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the,system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES:1/14 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is : i**+m vent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by�the Board of Health. (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / /\V CERTIFICATION (continued) Property Address: S L j 7 -k(,, `A Owner. 81ecL A h Date of Inspection: � J� /I Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(a). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:IV 4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE 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 analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S I LI Owner. Date of Inspection: L o �56 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine failure. what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: A//A The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S V Owner. 64.1 it'q+-c Date of Inspection: 8/20 /76 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A11A As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. JZThe system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. JZAll system components, excluding the Soil Absorption System, have been located on the site. ,V/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. JLThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S 1 y 6 G.k I Owner. ��C Date of Inspection: LJ 8'12 6 RESIDENTIAL FLOW CONDITIONS Design flow: :' d ns Number of bedrooms:_ Number of current residents: Garbage grinder(yes or no):-:�5 Laundry connected to system(yes or no):-5 Seasonal use(yes or no): At O Water meter readings, if available: g 5 = 00 o G Cho h 5 Last date of occupancy: /"t COMMERCIAL/INDUSTRIAL A.1/1 Type of establishment: Design flow:_ ona/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �lJr►Ap L a SL,o y S i9�•- �.{v O 6 i� C of 1. �, o ,,,t v System pumped as part of inspection: (yes or no)/A& If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tanludistribution box/soil absorption system Single oesspool G Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE A(,GE of all components, date installed (if known)and of information: A.;, «S S �e D✓�F w N I ,,�/--�/ (r�C iM . I , (r� (/ 7 3 O �"/� '�L../ fJ I �- 0.CA CjQ c iA .` Sewage odors detected when arriving at the site: (yes or no) /f e (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �1 . SYSTEM INFORMATION (oontinued) Property Address: s I L/ 6 a k l c- Owner. �o�N'1 u-h �- C._. Date of Inspection: la Q A SEPTIC TANK:_LV�/9 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:,d(/4 (locate on site plan) Depth below grade: 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 of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) g rt I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- C,.ti J. Owner. Date of Inspection: TIGHT OR HOLDING TANK,6[0 (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.) DISTRIBUTION BOX 1"11 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER:/V//9 (locate on site plan) r Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: ��y V Cl� w of . Owner. �rv-�h w h Date of Inapeotion: V/a 0 'i 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: 04^<- leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Co nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc) SD w w �l ✓ 3 c— C, cK < �-w c vt� CESSPOOLS: c w c 6Y rrob:c 5 -A*,A o'n.� ✓h�N s . (locate on site plan) Number and configuration: ti L pt., r i.. L c i S Depth-top of liquid to inlet invert: 6 Ur-•� . Depth of solids layer._ �� Depth of scum layer: IVO A14'= Dimensions of cesspool:_ 6 " J c- Materials of constriction: Cl-s s ,00 C. 1 L Indication of groundwater: l/O NC-- inflow(cesspool must be pumped as part of inspection)__ Cam—S 3 o y ( W Co- 3 CA�y u &1 S.eA— C—. T7a44 , Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetati n, etc.) a✓ q. oel(./ C� G t G.J v. .S c".a. S t /�► o s.� till. 0G S GJL L J✓ t L /�•L f t JW PRIVY: A/l (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,) (revised 11/03/95) S f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: s y Owner: Date of Inspection: 13 SKETCH OF SEWAGE DISPOSAL SYSTEM:- include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 86.L ,27 / a �sspoa I. • J DEPTH TO GROUNDWATER Depth to groundwater. --- feet adjusted high groundwater level method of determination or approximation: o � t.✓; r.�a .w �+ .. �zs . 3.� i 9 SECTION A -A SITE 1' = 2000' 10' min from "NOTE: ALL PIPES ARE TO BE ♦" SCHEDULE 40 P.V.C. VENT PIPE O Least 24 inches tan) ALL OUTLET PIPES FROM THE X a [house to septic tank schedule 40 PVC ./Cnorcool odor FUter PROFILE VIER' OF ADDITION .TO LEACHING SYSTEM aSTRftTI0N eox sw�L x t2_ CONCRETE �R •a, Li Q Existing Foundation Septic tank covers must be 3' of 1/8" - 1/2" Washed Peoston SET LEVEL FQR AT LEAST 2 FT. within 6 in of finished erode a0 3 s Grade over Septic Tank - 96.50 Code over D-So. - 9tl.50 ode over SAS -Varin From 9&00 to 95.00 3/4` t0 1 1/2 Washed Crushed Starve ,,,:r"-. } _ 5• OUTLET '.,�_` `.+.>, 2" ; Or Cr U - KNOCKOUTS s -15.5• a pv ouTLEr is �LF,> ;. a R S - 0.02 3 HOLE H-10 _ r 6• a J Q NEW DIST BOx 3' Maximum Cover Top of SAS - Elev. .92.75 ! - 2 In 0 R a S•0.01 a C+ater EXIST. PIPE 12' u) 1.500 GAL- s- o.ot• per foot • ~:1as'-.• P 0 FROM EXIST. rat1NDAT10N W SEPTIC TANK Effective Depth ; 4 - SCH 40 T t 75 L p tr H-10 8 5 Units @ 6' = 30' PLAN SECTION CROSS-SECTION Q-sift CONCRETE FULL FOBNDAT ° It 0 uT 1' 3' 3' c c b o+ C4 N 30' r o 6 in of 3/4"-1 1/2- V 9 36' 3 HOLE H-10 DISTRIBUTION BOX Qom X C SYSTEM PROFILE > compacted stone 5 I ' c c o zr ; p Effective Length NOT TO SCALE gyp' O L C U S M A P Not to Scale _ - > > 4' 4' > > .5 Z u > t0• 7E SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 in.of 3/4"-1 112' compacted stone E'F'c",.' vidtn o CULTEC MODEL 125 (H-20 LOADING)/ SHRVEY PRECASTE m 1. Contractor is responsible for Digsofe notification 139ttRm_nl_I9aL liets_]_Elex-�fr ------- (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. NOTE OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 12" 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Bockfill should be clean sand or grovel with no stones over 3" in size. - 4. This system is subject to inspection during nstallation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance PERCOLATION TEST with Title V of the Massachusetts state code, the approved plan to �} and Local Regulations. Dote of Percolation Test: APRIL 2, 2003 6. If, during installation the contractor encounters any Test Performed By. CARMEN E. SHAY, R.S., C.S.E. o� 1 soil conditions or site conditions that ore different Results Witnessed By. WAIVER ( per Bornstoble B.O.H.) i from those shown on the soil log or In our design Excavator: ROBERTS SEPTIC SERVICE VENT PIPE installation must halt & immediate notification be Percolation Rote: Less Thon 2 MPI c I mode to Carmen E. Shay - Environmental Services, Inc. 1 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. ++ ' 111.24' 1 9 -94 8. Install Tuf-Tite as baffles or equals on all outlet tee ends. Test Hole ! N 85d 11 25 E ' � 5 g No. 1 _____ V 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. z' 10. All solid piping, tees & fittings shall be 4" diameter DEPTH SOILS ELEV. --------_---`�---, Schedule 40 NSF PVC pipes with water tight joints. i 0 97 501 11. Municipal Water is Connected to The Residence and Abutting Ley ! i ` ; RESERVE AREA '4' Sand TEST HOLE #i -"' %i Properties within 150 Feet. I,' --- i I 95 10 YR 3/z � L----------------�_ _- ELEV.= 97.50 3G'` �r. :� A. 9�00 THE PROPERTY LINES ARE APPROXIMATE AND M. COMPILED FROM THE SURVEY PLAN GENERATED BY Loomy OLDE BOSTON LAND SURVEYING, OF NEW BEDFORD, MA ____4 Sand i� '--1 '___ ;; ;~ - 96 ENTITLED " SUBDIVISION PLAN OF LAND IN HYANNIS. MA, ,o YR s/6 �� / --, DATED SEPT. 6, 1966, 6"- 32" Be 94J5i �� / ASPHALT r_ I r' • '`t? `1`9� AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Medium / 0'- I j,:' IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Sand , ,� -- �RIVEVPar--- f - D-Box THE SEPTIC SYSTEM INSTALLATION. " 2 5 Y 8/6 / , / t f 32 96 9.50 1/ ' ____ I GARAGE t Medium Ip I 00 -- -_,I lob Foundation ,t EXISTING CESSPOOL TO BE PUMPED & FILLED IN PLACE. Sand 1 I N LiI 6'- 138" 2.5 Y 7/4 86 00' LOT #13 i wi Failed I\ ,,/ �� NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE LiI Ces`Tspool - b FROM THE EXISTING LEACH PIT TO BE DISPOSED it �t i L<h t1t OF AS PER BOARD OF HEALTH SPECIFICATIONS. 1 I I t t ti 1t 41 ` ��1500 GALLON PerC #1 t O, EXISTING 0V SEPTIC TANK LEGEND Depth Perc: 36" to 54" `�\ tt' O% '1 p 'i h\ (POL(POLYETHYLENE)NE) PerC Ratote= Less Tha 2 MPI 3 BEDROOM � Groundwater Not Observed O No Observed ESHWT 1� Q ' +n;c;pof <vi HOUSE PATIO '- .��, ; DENOTES PROPOSED ADJUSTED H2O Elev. = None \�\ �� 3 °f er4;ne� #514 `�_, 104X 1 SPOT GRADE Failed Cesspool DENOTES EXISTING X 104.46 NOTE: AT THE REQUEST OF BOARD OF HEALTH, �i -Afaf SPOT GRADE TEST PIT RE-EXCAVATED ON 4/4/03 TO PROVIDE 5' �`, ,' Lie DECK SEPARATION BETWEEN BOTTOM OF SAS i �q /' - PL PROPERTY LINE AND TEST HOLE DEPTH. PROJECT BENCH MARK TOP OF FOUNDATION 96P PROPOSED CONTOUR a LOT #14 ELEV. = 100.00 (Assumed) _ - _ _ - '' 15,290 Square Feet +/- -97 EXISTING CONTOUR TYPICAL 1500 GALLON SEPTIC TANK DEEP TEST HOLE & 116.50 PERCOLATION TEST LOCATION �� 3-24 a NN AM. ACCESS MADLEs NOT TO SCALE 6 FOOT STOCKADE FENCE ' O 4 2CID 78d 3 lc� REV.: 4/4/03 - Test Pit Re-Excavoted for 5' Separation & Reserve Area Shown P LOT PLAN THE ACCESS COVERS FOR THE SEPTIC TANK, 414 DISTRIBUTION BOX AND LEACHING COMPONENT : SHALL BE RAISED TO WITHIN 6" of _ _`1 DO _ OF PROPOSED SEPTIC SYSTEM UPGRADE AQ'-� ' " FINISHED GRADE LOT # >5 STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS M ��1J�"+; ` PREPARED FOR ON ALL OUTLET TEE ENDS PLAN VIEW T�SIA c�R*a� g, V•4 '' CID ^���.oNANDltss'C MR . RICHARD ECKHART ,a, ��1�M W®,���• AT r ? r, � 3-24 REMOVABLE �°��� ��� # 514 OAKLAND ROAD m HYANNIS M A Y e4[T ftJT Ti* in Clearance mm _�Lmn. Net to outtet 4. tNLE - - - --•La+a te..+ �20 OUTLET . >a'm� Design Calculationst 5' -7" * --- t -- 5' -7 PREPARED BY E - 4•-0- min°j~" Liquid depth s Number of Bedrooms- o 3 Equivalent to 330 Gal./Day (330 Gol./Day Min. per Title v) Tt' < H ` dyT o Y Garbage Grinder: N R \ C�R�IJ�'N E. SWAY , s t� +� Leaching Capacity Proposed: 330 Gal./Doy Minimum (Min. Per Title V) j • Septic Tank - 3 x 330 Gol./Day = 660 USE 1,500 GAL. Septic Tank. 0 20 40 50 �E �„�, °' , - SOIL ABSORPTION AREA: Using percolation rote of <2 min./inch ENVIRONMENTAL SERVICES INC. 10'-0• ' s, 1 No i1 CROSS SECTION END-SECTION Bottom Area: 0.74 gol/sq. ft x 360 sq. ft = 266.4 gallons � P.O. BOX 62� Sidewoll Area: 0.74 gol./sq. ft. x 92 sq- ft. = 68.08 gallons E`i` EAST FALMOUTH, MA 02536 Providing: 334.48 gallons AS°MT `W TEL/FAX : 508-548-0796 MAY REPLACE WITH 1500 GALLON POLYETHYLENE SEPTIC TANK) Use. (5) CULTEC MODEL 135 UNITS, HAVING A 1' EFFZCTIVE DEPTH, SCALE: 1 "=20' --• TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE SCALE: 1 "=20' DRAWN BY: CES DATE: APRIL 3. 2003 FROM GEORGE OBRIEN & COMPANY (H- 10) ON THE ENDS. NO STONE UNDER. PROJECT#SD407 FILENAME: SD407PP.DWG SHEET 1 OF 1