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0116 OLD TOWN ROAD - Health
6 Old Town Road Hyannis,, A= 268 - 083 . r I TOWN OpF�BARNSTABLE LOCATION (S)J—b7!btA" W . SEWAGE# ZoZ t ' o 1 S VILLAGE y A I-Jr4 15 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Oe 6S01q)\q I I-88.7 SEPTIC TANK CAPACITY ,y LEACHING FACILITY:(type)5OOqoA. CAAMj EELS (size) Ite.S- '-c V-S3 . NO.OF BEDROOMS Z. OWNER L Qu E YCC.I-'1 PERMIT DATE: 3 I15 I ZI COMPLIANCE DATE: 2 P Separation Distance Between the: /� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �0 PLO® �' 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 �o �2T Ou- LO. J • s �IvaW^ c c A t3 �3 is 1-7 14 2"l Zo 2 23 22 S Zo 2J � l -� TOWN OF BAARNSTABLE LOCATION ,�1� Ql� / OGUi1 IG C• SEWAGE# J VILLAGE �'1 y/ )Ai f ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY " W S M 1 LEACHING FACILITY:(type) 10, - (size) 4Ub NO.OF BEDROOMS OWNER PO Lie, PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ) Feet FURNISHED BY �/1 SfLUT1 U7 J F" COO CD c) Q J - Q I� v d LOCATION SEWAGE PERMIT NO. VILLAGE I N S T A LLElk NAME & ADDRESS I B UItDE R OR OWNER /) �8/I DATE PERMIT ISSUED �z _ DATE COMPLIANCE ISSUED , r c a r No.� Fee THE COMMO LTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWOF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(Y) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 11,6 OLD-Tow- Rj Owner's Name,Address,_an_d'Tel.No. Assessor's Map/Parcel oQ& 3 64 Y �AS I i e- 4 1� Installer's Name,Address,and Tel.No 0$—477-8Y77 Designer's Name,Address,and Tel.No. I MPS<gLct_O /y 48 OkylL . A3 i���,.6 'R,� Yam,, ov Val l 1 cjl,^o� l55 �e®2yekr �l s.�i.w Type of Building: GL Dwelling No.of Bedrooms Lot Size 60® sq.ft. Garbage Grinder( ) Other Type of Building 1A-SIA A No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) (71a� gpd Design flow provided gpd Plan Date 3 Number of sheets 61) Revision Date Title Size of Septic Tank I500 Type of S.A.S. Tf—Gc1J-'^vJ Description of Soil LOe.�v► .Sc rt(/ 4c, /u m tj t5u p lc`.% Nature of Repairs or Alterations(Answer when applicable) new lJ oo 6c,16A J �_ (%�A L AW �o Box ck and -'tom So6 6 c1N on Lecci,, C k.a,,�e 60e PICA) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date ���" Application Approved by Date ../ /S Application Disapproved by Date for the following reasons Permit No. n fTj�' Date Issued 151 p No. "C7! *2_5 Fee r 40 0 THE C0MM0`hIQffAWLj,0F MASSACHUSETTS Entered in computer: PUBLIC HEALTH`DIVISION - BARNSTABLE, MASSACHUSETTS. Yes application for Disposal 6pstem Construction 3Prrmit Application for a-Perniit to Construct( ) Repair( ) Upgradef-Y)-Abandon( ) ❑Complete System ❑Individual Components -0 Location Address or Lot No. 11� OLD low^ IZ cl� Owner's Name,Address,and Tel.No. ' ;4 r 5 , ' Assessor's MapLParcel �,� �' 4�10� LAS fl � �"•� Installer's Name,Address,and Tel.No. `5(�8T t'1W-V7"J Designer's Name,Address,and Tel.No. y ber $ S 3 tn� �s c�Y �ravv ,: , Y+u�+at I5' Q I?ci S• a.. . Type of Building*= i Dwelling No of Bedrooms ; Lot Size, ° l °sq ft?: Garbage Grinder Other Type of Building FaSICilA��G,� No.of Persons Showers( ) Cafeteria Other Fixtures /t ` f Design Flow(min.required) Slab ` gpd Design flow provided ��� gpd Plan Date i` a��'" Number of sheets Revision Date Title Size.of Septic Tank 0Cl T' e of S.A.S. � Cn �t I-o P YP •1 ` � ^*,. L'C 4�S I Description of Soil `,oo my Sko d -�a f tdjtl wj nj 1.T Q� } f � Nature of Repairs or Alterations(Answer when applicable) new 1506 6c jjorn 'Sep�"G -S09 C%Na lktov _ ace 6r,11on 0ev 1p14n Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign e -- . Date Application Approved by Date Application Disapproved by Date ' for the following reasons e Permit No h ( ""' Date Issued . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS rr _ Certificate of Compliance r ' THIS IS TO CERTIFY,that thebri-site Sewage Disposal system Constructed( ) Repaired( t ) Upgraded(X) Abandoned( )by OU12 .I:"6 4 _.. - _.. at 1 115 OLD ITOL i— ke � Jlvi/ . n t k has been constructed in accordance } , with the provisions of Title 5 and the for Disposal System Construction Permit No y,?/^"f) dated n Installer° MGM r t 11I °„r Designer Pgu t Cl 0 q1 h q A Q tV #bedrooms Approved design flow _ and The issuance of this pe, 't shall not be c/o istrued as a guarantee that the syste ill funcI/nas designed. / \ Date �� � ) Inspector "^�_ ' P _. .._�...-No a� � ��� -_.---.---.---._.._ �_�..�b_.�r.....-..-_.-.._,_._._�..----•------•--•-•-------•----- Fee THE COMMONWEALTH OF MASSACHUSETTS r� 0%A PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade(No Abandon( ) System located at !b OLD 'T®u)r\ . kt7t. #� , 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. 1 Provided:Construction mus be completed within three years of the date of thil4 rmit. Date 31151a APProved"by,„_ s r TESTBOG ' '. DESI N cCALLCcCULATT O ALUATOR: DAVID D. COUGHANOWR, ASE *461 DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPD ESSED BY: DONALD DESMARAIS. HEALTH DEPT. SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS PIT 1 NO GROUNDWATER ENCOUNTERED INSTALL NEW 1500 GALLON SEPTIC TANK. PERC AT 62 in - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER v -DISTRIAUTION BOX: INSTALL UNIT DEPICTED BELOW. 38.55 INCHES HORIZON TEXTURE (MUNSELL) MOTTLES SOIL ABSORBTION SYSTEM: 0-12 FILL THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 12-16 O LOAM 10 YR 2/2 NONE FRIABLE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 16-20 A SANDY LOAM 10 YR 4/6 NONE FRIABLE PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. 35.72 20-34 B LOAMY SAND 10 YR 5/6 NONE LOOSE THE LEACHING GALLERY DEPICTED CAN LEACH: 27.88 34-128 C MEDIUM SAND 10 YR 5/4 NONE LOOSE BOTTOM AREA = 16.5 x 21.33 TEST PIT 2 NO GROUNDWATER ENCOUNTERED -1/2 (14.83 x 6.3) = 305.23 sq. ft. - 2 MIN/INCH IN C SOILS SIDEWALL AREA = (16.5+6.5+16.12+ ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 10.20+21.33)x2 = 141.30 sq. ft. 38.40 INCHES HORIZON TEXTURE (MUNSELLI MOTTLES TOTAL AREA = 446.53 sq. ft. 0-10 FILL FLOW CAPACITY = 0.74 x 446.5 = 330.4 gal/day 10-15 O LOAM 10 YR 2/2 NONE FRIABLE INSTALL THE LEACHING GALLERY AS CONFIGURED BELOW. 15-20 A SANDY LOAM 10 YR 4/6 NONE FRIABLE FLOW CAPACITY = 330.4 gal/dog WHICH EXCEEDS THE 35.73 20-32 B LOAMY SAND 10 YR 5/6 NONE LOOSE 220 gol/dog REQUIRED FOR A TWO BEDROOM DESIGN. 32-128 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 27.73 _ SS09L QBSORPT§ON 1500 0o GALLO SEPT#C TANK . S YS 7 EM CONSTRUCTION DETAIL DIMENSIONS ,& .DETAIL USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL INSTALL TWO DRYWELL 6.50 ft 14.83 ft UNITS AS SHOWN ,. I in WITH UP TO 4 FEET OF 16 TAPER STONE ALL AROUND. /2 ft co �1 MARK INSPECTION O + p � �! RISER WITH 10 cl S ft- MAGNETIC TAPE. 0 O { C 8 in O DRYWELL F UNIT 21.33 ft NOT TO 500 GALLON DRYWELL �� 1ct-05 SCALE DIMENSIONS INSTALL ONE INSPECTION RISER /n TO WITHIN THREE INCHES OF & DETAIL FINAL GRADE & INDICATE LOCATION ON AS-BUILT INLET OUTLET " USE COVER COVER 33 H-10 u OD in UNI T s._ �3 /N DROP FLOW LINE K` FROM i 10 in = __- _.< .4 TO 5� BUILDING ;fir i� D-BOX 102 in 48 in LIQUID GAS CROSS SECTION VIEW LEVEL BAFFLE INSTALL AN APPROVED GEOTEXTILE FABRIC OVER STONE 6 in STONE BASE �V_ ® 24 in a ) 3/4 ,n TO 3/4 in TO SEPARATION BETWEEN INLET & OUTLET 28 xl 1/2 m ORAVEIo EFFECTIVE®►-1/2 In GRAVEL TEES NO LESS THAN LIQUID DEPTH in }: k o DEPTH CROSS SECTION VIEW 48 in MAX 58 in .48 in MAX D9ST 90UT00o nNl 900X DB-3 H20Y DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL AND DETAIL FOR 2 FEET,BEFORE PITCHING DOWN -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE N STARTING WORK. ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM 9 12 In ��� REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC c MIN CODE (310 CMR 15). -► -INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND L FROM i' S S TQ UTILITIES BEFORE EXCAVATING FOR SYSTEM. N TANK AS a n TO -ECO-TECH RAPID RESPONSE RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES, AND PERIODIC PUMPING OF THE SEPTIC TANK. ` \� 6 STONE BASESYSTEM NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. 2/ in 2 CROSS SECTION VIEW DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. (� O W p G3 O F L C TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 40 PVC EL = 40.05 +- A�x in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 38.50 D�BO}� 3. ,..,� ,. ,. M A X USE H-20 N8���L,� 36.25 37.5+- 1500 C310,LILO0N PRECAST &0 0 0°0°0 °oo�a�ao o°a°op°p°oa°oS °oSo�o°o°° EXISTING SEPTIC TA INK K 36.50 35.58in DRYWELL •o ° 30.75 REFER TO DETAIL BOX ST ONE SOIL QBSORPP TON + 35.75 BASE 35.50 -REFER TO 4- 41 ft e ,n STONE BASE 44 fr 5-9 ft ������ DETAIL BOX q 33.50 NO GROUNDWATER BELOW MOTTLING OBSERVED _ 27.73 SEWAGE DISPOSAL SYSTEM PLANJI 116 OLD TOWN ROAD HYANNIS, MA71MARCH 11. 2021 ETE-4542 PG 212 THIS IS A COLOR OQ e�NSSpgLE GIS DAT e ELEVATION PLAN EGASL E �o— • ' • � ' USE COLOR PLAN bNLY - e 40.05 FOR INSTALLATION TE 0 e P FOUNDP� FULL DETAIL IS BEST - OF VIEWED INFULL COLOR WIR OH EXISTING CESSPOOLS INCLUDING ANY NOT SHOWN ON THIS PLAN ARE TO BE LOCATED AND SHALL BE PUMPED, COLLAPSED AND FILLED. 38 90.72 ft 39 w ,� 38 M ao o s o. }. "M � W, � �g 17 T w \71(_ µ ` W P ................. m MINIMAL rAyfy a GRADING PROPOSED I J Ix1 x W LOT I 39 AREA = 10600 sf+- w PLAN BOOK 257 PAGE 93 p A ��x,rf ASSR MA1�26H PaH3 1 3 �Q20 in OAK OWED � r ` 10 ft RX , W LEGEND SEPTIC COMPONENTS — 63.95 ft 1500 GAL SEPTIC TANK FIL�A #'V 0EXISTINGPROPOSED SOIL LEACH wTi SCALE: 1 in = 20 ft CESSPOOL ABSORPTION D 20 4 - - ___-- ° SYSTEM DISTRIBUTION BOX TEST PIT rN® O 10 20 -SEE DETAIL ON BACK CLEAN OUT PRINT ON 8-112 x 14 in TO GRADE PAPER FOR PROPER SCALE THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS, OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. 'b 4 "'Drive- n =� SEWAGE DISPOSAL m MASs9 \ `� J y ` � SYSTEM PLAN y�� Sd�rise" �S a ��? �P�SH GF MASS9 -TO SERVE EXISTING DWELLING a ater@ceA ya �y DAVID �G DAVIDD. LESLIE G d �pi�eTerrace° Sertacec5 � � � fola `rso ahug eHA090WR <n v COUGHANOWR v 3 A. KO CH No. 461 "\�, • • OWNER(S) OF RECORD COUG 1p, 16 OLD TOWN ROAD ,� Joa - = °� � HYANNIS, MA y 04� xeca 9155 Geo Ryder Rd 5 ROPERTY ADDRESS �`eR"4e Chatham, MA 02633 HYANN/S DATE: MARCH 11• 2021 Davidcou@HotmaiLcom L 0 C U S MAP 508 364-0894 P�JjDe# ETE-4542 M'o" Town of Barnstable Regulatory Services Richard V. Scali,Interim Director BARNSTABL& MAS& Public Health Division . 019. . A'fo► r+ Thomas McKean,Director 206 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 3/23/21 Sewage Permit# ZQIZ( -Ol Assessor's MaplParcel 268/83 Designer: David D. Coughanowr RS Installer: 4�T 6- OLAZ Co. Address: 155 George Ryder Rd South Address: 3(e3 04+tTE5 -8+}4 Chatham, MA 02633 51XQ40V ,_ pZ b(,l On 3 (S Z l go&V,' J3 . 10L4.4f, was issued a permit to install a date) (installer) septic system at 116 Old Town Road based on a design drawn by (address) David D. Coughanowr dated 3/11/21 (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or, septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic; system referenced above was installed with major changes i.e. & � greater than I O' lateral relocation of the SAS.or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters(if applicable) A"o6 r f4s Aa OF h s� 11�cs/�__ ° DAVIG1 �o`` FJAID _a+ In Caller's Si a e .� '' ,p•,; ._ � ' �. ( Sn ) COUt;ti�ltVOWk COUGHANOWAM. t c (Designer's Signature) ner's Sta PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QAScptic\Dcsigncr Certification Form Rev 8-14-13.doe BRB/FND _ 103.25 ' N 89 30" E 102.61 C RND/FND 90.72' 104.87 �5, 10.0' 104. 04.1� d DIM BID P��e Exist. S.A�S. er Town 103.29 O.H.W 104.7) `� ►� UP 0 \ Exis t. D wg. 1 N 102.95 A \ 1116 s 1 TOF=105.70 z \ \ (Assumed) O N \ Dec \ X la` ' 103.12 � \ r --\ \ \ Lot 1 { N 0 -o \ 10,273f S F. (10,600t Deed)CD o \\ X 104.36 O 104.26 fl 103.1 20. \\ 1�4.05 . BRB/F ID _ 103.71 Goroge 1 4• 1 1003e� v 103.11 102.94 A Dr1�e ,103.93 , BRB/FND w LA 102.82 0 102 - — — — — — — fo.o' CB/RND/FND 10.6, 100.59 63.95, S 8920,500 W TOWN OF BARNSTABLE ZONING 102.48 BY-LAW STREET ADDRESS: 1116 OLD TOWN ROAD ASSESSORS VAP 238 PARCEL ZONE RB OWNER., GREG & LESLIE KOCH 83 SETBACKS : DEED REF.:, BK. 32061 PG 61 FRONT = 20' PLAN REF.: PL. BK. 247 PG. 93 LOT 1 . SIDE = 10' REAR = 10' I CERTIFY THAT TO THE BEST OF MY PROFESSIONAL KNOWLEDGE, INFORMA770N AND BELIEF THE DWELLING PROPERTY LINES SHOWN HEREON SHOWN HEREON CONFORMS TO THE HORIZONTAL SETBACKS WERE COMPILED FROM AVAILABLE OF THE ZONING BY-LAW FOR THE TOWN OF BARNSTABLE. PLANS OF RECORD AND VERIFIED ON THE GROUND. PL 0 T PLAN THE DWELLING DEPICTED ON THIS SHOWING PROPOSED ADDITION PLAN WAS LOWED ON THE GROUND IN BY SURVEY ON JULY ,17, 2019 AND BARNSTABLE, MASS. EXISTS AS SHOWN AS OF THE DA 1E OF LOCH 770N. SCALE: 1"=20' JULY 23, 2019 THIS PLAN IS FOR PLOT PLAN TERRY A. WARNER, P.L.S. PURPOSES ONLY. 22 LONG ROAD HARW/CH, MA. 02645 (508) 432-8309 0 20 40 60 THIS PLAN IS VOID IF NOT STAMPED AND SIGNED IN RED. PROJECT NO. 19-190 I Commonwealth of Massachusetts -_ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every H annis MA 02601 March 7, 2011 Y page. Citylrown 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Environmental my Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 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: LIJ � Passes ❑ Conditionally Passes ❑ Fails t...� F..0 ❑ Needs Further Evaluation by the Local Approving Authority � S March 7, 2011 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 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. f 15ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts l - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 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 ® 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: Inspectors Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Inspector recommends larger cover for primary cesspool. 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): 15ins-09VI 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 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7 2011 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 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 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 Y day flow t5ins•09108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 0117 Commonwealth of Massachusetts -__- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 page. Cityrrown 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 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 15.304. The system owner should contact the appropriate regional office of the Department. !Sins 09108 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 116 Old Town Road Property Address Estate.of Edward Powell, c/o Robert Powell Owner Owner's Name requiratifore Hyannis MA 02601 March 7, 2011 required for every Y page. Citylrown 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 Q ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 Has the system received normal flows in the previous two week period? ❑ f Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Q ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑X ❑ Was the site inspected for signs of break out? 0 ❑ 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? Z ❑ 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: U ❑ Existing information. For example, a plan at the Board of Health. Y ❑ 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): 2-3 DESIGN flow based'on 310.CMR 15.203 (for example: 110.gpd x#of bedrooms): n/a -no plan t5ins,09108' 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 ti 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every H annis MA 02601 March 7, 2011 _Y page. City/Town State Zip Code Date.of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ . No. Seasonal use? ❑ Yes 0 No Water meter readings, if available (last2 years usage (gpd)): 0 gpd Detail: 2009-2010 Sump pump? ❑ Yes 0 No Last date of occupancy: undeterminedDate Comm ercialllndustrial 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys{em•Page 7 6I.17 Commonwealth of"Massachusetts T i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Old Town Road Property Address Estate of'Edward Powell, c/o Robert Powell Owner `._.,. _w Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 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: - Was system pumped as part of the inspection? ❑ Yes ❑X 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 (X] Overflow cesspool Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records; if any) El 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 11A system by system operator under contract ❑, Tight tank. Attach a copy of the DEP approval. El Other(describe): t5in„•09108 - Title Official inspection Form'Subsurface Sewage-Disposal-System-Page 8of 17 Commonwealth of Massachusetts Tulle 5 Official Inspection For _ - s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7,.2011 page. Cityrrown State Zip Coded Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age 32+ years. Overflow cesspool was added 9/27/78 (previous ins e_ction report). Were sewage odors detected when arriving at the site? ❑ Yes © No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): D'epth.below grade: 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: Sludge depth: 15uu•09= - Title 5 Official Inspection Form:.Subsurface Sowago Disposal Syslem•Pago 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner ------ ----..._-..------ ..----- - Owner's Name information is required for every Hyannis annis MA 02601 March 7, 2011 page. City/Town Slate 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 - -- — -- Distance from top of scum to top of outlet tee or baffle — 'Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•09108 Title 5 Official Inspcoon 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 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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�09M Tille 5 Official Inspection Form:Subsurface Sewage Disposal Syilom-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7,2011 page. CityJTown State Zip:Code Date of Inspection D. System Information (coat.) Distribution Box (if present must be opened) (locate on site plan): f 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.): 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.): Soil Absorption System (SAS):(locate on site plan, excavation not required): If SAS not located explain why: t5ins•090 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Name information is required for every Hyannis MA 02601 March 7, 2011 page. City/town State Zip Code. Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: 1 '❑ 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.): Soils above overflow cesspool appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence.of hydraulic failure was observed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in series:-primary described here Depth-top of liquid to inlet.invert 3.5 ft Depth of solids layer 6 in Depth of scum layer 5 in. Dimensions of cesspool 5 It x 6 ft Materials of construction concrete block Indication of groundwater inflow ❑ Yes No i5ins•ostoe 7illo 5 Official Inspection Form.Subsurface Sewage Disposal Systom•Pago 13 a!17 Commonwealth of Massachusetts _ Title 5. Official Inspection Form Subsurface Sewage Disposal System Form Not.for Voluntary.,Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner Owner's Narne information is required for every Hyannis annis MA 02601 March 7,:201,1 . page. Cityrrown State Zip Code Date of tnspdption D. System Information (Pont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Outlet tee present. Larger cover for primary cesspool is recommended. No lush vegetation or other evidence of hydraulic failure was observed. 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.): t Ins•09108 Thlo 5 Official Inspociion.Focm:Substafaco Sewage Disposai.System•Pape 14 of 17 Commonwealth of Massachusetts i Title 5 ffici0 Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell Owner owner's Name information is required for every Hyannis MA 02601 March 7, 2011 page. Citylrown 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 L� 4 r— 2-2Y2 2 OvERi-�.oW CP w O`D T()L,,N i Pr Isms-09= Tillo 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of'17 ;0. Commonwea th of Massachusetts C Title 5 Off icia� Ins'pection Form =1 Subsurface Sewage Disposal System Form -Not for'Voluntary Assessments 116:Old Town Road Property Address Estate of Edward..Powell, c/o Robert Powell. Owner Owner's Name information is requited for every- Hyannis MA 02601 March 7, 2011 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 Ovate;: 30 ftfeet Please indicate all methods used Wfle.termine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate -� ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Previous inspection report ❑ Checked with local excavators, installers -(attach documentation) Accessed USGS database explain: You must describe how you established the High ground water elevation: Previous inspection report indicates property is 30 feet above high groundwater elevation. Before filing,this Inspection Report, please see Report,Completeness Checklist on next page. Ohs•09108 r0o,5_0ffi6til Inspection Form:Subsurface Scoka96 Disposal.System•Page 16 of 17 s Commonwealth of Massachusetts } Tifle 5 Offida0 �nspeetaon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Old Town Road Property Address Estate of Edward Powell, c/o Robert Powell _ Owner Owners Name information is Hl annis MA 02601 March 7 2011 required for every _y _,___ page. City/Town State Zip Code Date oftnspection 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 X Sketch of Sewage Disposal System either drawn on page. 15 or attached in separate file System n1 p •Page 15ins•O9/OC Tr m'to 5 Oti,c:al t::-anon For Sunsu:ln:u S&.t•ago Oi5 o ys s $ e of 17 a, TOWN OF BARNSTABLE LOCATION 0 O�C TQ(N,I P . SEWAGE# VILLAGE YAtion1 S ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY C2 J SP CM LEACHING FACILITY:(type) (��T (size) QUb NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r/lsoarion J FQi� l0 as' G� C a (3Ac,k A 6 aa- as � a - 3k r �> rw i K 7 s 1 OEM, 911 40 RR d 4 �,� � k.0 n .1.3'�, �"i�". is r .�,• a �n �S`,� - r < . 's "I Ir . . 1 J ; COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM FORM' 'PART A 4 CERTIFICATION . Property Address:- 116 Old Town Road Hyannis, MA 02601 Owner's Name: Robert Powell ' Owner's Address: 35 Victorian Drive : Old Bridee, NJ 08857 - wa a' Date of Inspection: October 25, 2007.. Name of Inspector:(Please Print)Janes M. Ford Company,Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.-MA:02655=0049 Telephone Number:. (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based'-on my ,training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.346 of Title 5(31-0 CMR 15.000). The system:: Passes C ditionally Passes N. e s Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Dater November 2. 2007 . The system inspector shall sub it 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. _ Notes and Comments ****This report only describes condition s`at the time of inspection and under the conditions of use at that . time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 Old Town Road' Hyannis, MA. Owner: Robert Powell Date of Inspection: October 25, 2607 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:' ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System,Conditionally Passes: One or more system components as described in the "Conditional,Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer,yes,no or not determined(Y,N,ND)in the for the following statements. ;If"not determined".,please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrationor 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. NDp ex lain: Observation`of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,`settled or uneven distribution box. System will pass inspection if (with approval.of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than,4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board..of Health): broken pipe(s)are replaced: obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 Old Town Road Hyannis:MA Owner: Robert Powell Date of Inspection: October 25. 2007 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 316 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a.bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health.(and Public Water Supplier,if.any).determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank'and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has aseptic tank and SAS and the SAS is within a Zone 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 coliforin bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure,criteria are triggered.`A.copy of the analysis must be attached to this form 3. Other: . 3 Page 4 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 116 Old Town Road Hyannis, MA Owner: Robert Powell Date of Inspection: October 25: 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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''/z 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 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 iswithin 50 feet of a private water.supply well.', _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50`feet from a private water supply:well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified laboratory,for coliform bacteria and volatile organic:compounds indicates that the well is free.from pollution from that.facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner shouldcontaci the Board of Health to-determine what will be necessary to correct the failure. E. Large System: To be considered a large system.the system must serve a.facility with a design flow of 10,000 gpd to 15,000 gpd• ` You inust indicate either"yes"or"no".to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system.is within 400 feet of a surface drinking water,supply „ the system is within 200 feet of a tributaryto a surface drinking water supply " the system is located in'a ntrogensensitive.area(Interim Wellhead Protection Area IWPA)or.a mapped — — Zone I1of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner.should contact the appropriate regional office of the Department. 4 I Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 Old Town Road Hyannis, MA Owner: Robert.Powell Date of Inspection: October 25, 2007 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 7 ✓ 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 Old Town Road Hyannis, MA Owner: Robert Powell Date of Inspection: October 25, 2007 FLOW .CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on.310 CMR 15.203 (for example: 110 gpd x#of bedrooms) 220 Number of current:residents: n/a Does residence have a garbage grinder(yes or no)- n/a Is laundry on a separate sewage system(yes or no):. n/a [if yes separate inspection required] Laundry system inspected(yes.or no): No Seasonal use(yes or no): . No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no):- No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow,(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or'no) Non-sanitary waste discharged to:the Title 5 system(yes or no): Water meter readings,if available: . Last date of occupancy/use: t OTHER(describe): .GENERAL INFORMATION Pumping Records Source of infornation:� .Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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) Tight Tank Attach a copy of the DEP approval Other(describe):. _ . Approximate age of all components,date installed(if known)and source of information: Date of installation unknown. A pit was added on 9127178(per as built card) Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 Old Town Road Hyannis. MA Owner: Robert Powell Date of Inspection: October 25,2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC - other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) - (Cesspool acting as a septic tank) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene other(explain) cesspool block If tank is metal list age: Is age confirmed.by a Certificate of Compliance(yes or no): {attach a copy of certificate) Dimensions: 5'W x 4'T x 6'6" Sludge depth: 6„ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 5 Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle:' How were dimensions'determined: '' Measuring 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.):. The liquid level was up to'the outlet tee. The cover was 2"below grade GREASE TRAP.:. None.(locate on site plan) Depth below grade: Material of construction:: ._concrete metal _fiberglass _polyethylene _other (explain): - Dimensions: Scum thickness; Distance from top of scum to top of outlet_tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: - Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,.liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 1.1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116.Old Town Road Hyannis, MA Owner: Robert Powell Date of Inspection: October 25 2007 . TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: .-_concrete _metal.—fiberglass _polyethylene _other(explain): Dimensions: Capacity: eallons Design.Flow: gallons/day . Alarm present(yes or no): Alarm level: - Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order.(yes or no): Alanns in working order(yes or no) Comments(note condition.of pump chamber,condition of pumps and appurtenances,etc.): 8 a Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 Old Town Road Hyannis, MA Owner: Robert Powell Date of Inspect►on: October 25, 2007 SOIL ABSORPTION SYSTEM(SAS):. ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 6'x 6'(1.000 awl.)_ 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.):The pit had 4'of Quid on the bottom. The scum line was d roximatel 5'up ronz the bottom. There did not appear to be any signs offailure. The bottom to grade was 8' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate:on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): I PRIVY: None (locate on site plan) Materials'of construction: ` Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I 9 Pag e.10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 Old Town Road Hyannis. tYIA Owner: Robert-Powell Date of Inspection: October 25, 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide.a sketch_of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within.10.0 feet. Locate.where public water supply enters the building. C a (3AUk A 8 i 10 Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 Old Town Road Hyannis, MA Owner: Robert Powell Date of Inspection: October 25, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells . Estimated depth to ground water 30+/.- feet Please indicate(check)all methods used to determine the high ground water elevation. Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: toraphic and water`contours maps Checked.with local excavators,installers-(attach documentation) Accessed USGS database-:explain: You must describe how you established the.high ground water elevation: Using Barnstable topographic and water'contours maps, the maps were showing gpproximately 30'+1-ground water at this site. This.report,has been prepared only for the septic system and components described herein. This septic system has been inspected and passed'as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in.the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the septic systein, the inspection, this report andlor any components of the septic system which have not been located and inspected: 11 7 g ��. a -.. �5�00 zf Fss, i Nob- ---•-• ---- ............................. THE COMMONWEAL..i H OF MASSACHUSETTS BOAR® Off` 'HEALTH -.............._.Town...........OF...........B rU takle............................................. t Appliratio t for Uiipniial Workii Tomiuttrtinit Permit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: . 116...old....T.oarn...ad.......fwes.t....Tiyanniapart --=---------------•-------•-•-----•----...----•------ Location-Address or Lot No. mgvlley_... .o�...................... raigvlle ?beach_.Rd...,....yY.._.�iyd . port Owner Address a ._. __. ... ess�ool Service......---.-•------•------------ 1.28 �i1aho�o....Temr�.ce.,...Hyanni.s................ Installer Address Type of.Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................3.................Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building ............................ No. of persons.......¢.................. Showers ( ) — Cafeteria ( ) A' 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aa Test Pit No. -................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------•--....•-•-•-••----.............---••-•---....-----•--•--------......................................................... 0 Description of Soil........zanJ-----------------------------------------•-••..-•-•=-••-••••-------••••-•--•---•--•----•......----•--•-..........- x x -----••••--•....................••-•--•••--••---••••----------------•---•-•-••-•••---•--•--•-•-•-•••----•••••--•--------•••---------•••••--••-••-•••-•----•-•-----•-•--•••••••.....•-••••-•-•--•--•••-- :r U Nature of Repairs.or Alterations—Answer when applicable.__--,00---�..orie....thauzand. ...P,s.a 1rlan-------------- ...a atone .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b he bo f ealth. d _ '-}_-.-.,*...................... ....912-71.78-----•- Date Application Approved By---•� �e� e... � - -`.�a (, Date Application Disapproved for the following reasons---------------- -------------------------•------------------------------.................................. •-••-••••-•-•••-•...........•••-••---•...............•-••-•-•---•-••---•-•--••••••----•--......••••---•-•--•-••-•---•••--•••-•---••....--••-------••----•-----••-•••---••••......---------•---•••-•..... Date PermitNo......................................................... Issued....................................................... Date FRic...$2..'.0.0......... Aj ..... ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................Town-...........OF................OF...........Barnstable.-------_----------......................... Appliration for Uh4posa1 Vorkg Tomtrurtion "trutit .,,,4ipplication is hereby made for a Permit to Construct or Repair X) an Individual Sewage Disposal System at: 114... _*l -Pt iiyaantape>r-t .................................................................................................. ,c,In I di or Lot No. Grzigrv-i-110... --------------------------------------- CraigVille...BO.&Qh---RdAL.s..x*....F4.amnlmp.ort Address &---�__.ceaspDai...servize.................................. 12B...Biahopa...T.er-rxce.,...Hyanr).is................ Installer Address Type of Building Size Lot____ _________ .....Sq. feet U Dwelling—No. of Bedrooms..........................3__________-_____Expansion Attic Garbage Grinder ( 1:14 Other—Type of Building ............................ No. of persons.......4.................. Showers Cafeteria ( 04 Other fixtures ........................................................................................................................7............................ Design Flow____..__...................................gallons per person per day. Total daily flow____.____.__._._.______-_!�.................gallons. 1:4 Septic Tank—'Liquid capacity------------gallons Length________________ Width_______________. Diameter__.:__.._...1--- Depth________.__..... Disposal Trench—No_ .................... Width______.__.____.___.. Total Length_______.____.__.._._ Total leaching area----_-------------sq. f t. Seepage Pit No..................... Diameter._....__.__..___._._ Depth below inlet____.___..._..__.._. Total leaching area..................sq. f t. Z Other DistributiQ4 box Dosing tank Percolation Test4kesults Performed by.......................................................................... Date........................................ Test Pit 15o. I................minutes per inch Depth of Test Pit..._.________._.____ Depth to ground water_-____________________-. (i Test Pit No. 2................minutes per inch Depth of Test Pit....__._____._______ Depth to ground water..._________________._.. ------------------------------------------------*-------------*------------------------------------------------- -------------------------------------- 0 Description of Soil___.__.__,_ U ...................................................................................................................................................... ............................................ ...................................................................................................................... ................................................................................ U Nature of Repairs or Alterations—Answer when applicable...1.0.0.00...(one---thousLand.)...gallon-_--------- ...at.one----paeked----Iaaclx...pit................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e board f li Ith. E ... ....... .................... .....912.7/78-------- te Application Approved By....'O.Zl Arl . ........................... ....................................... Date Application Disapproved for the following reasons:........... ..................................................................................................... ...........................................................:-------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued---------------------------------- Date -THE COMMONWEALTH OF MASSACHUSETTS BOARD O%HEALTH ..................Mown...........OF................B,a-ur, ia�-table...................................... Tertifiratt of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired io ...12a...Bla-ho-pis...a!er.rac.e.._,Hy.ann1.s.......................................... at...116...old....T.own... t..._.. raig,,villa...:jit�y...................................... ,,yanpiapor_ _ has been installed in accordan c'e with the provisions of TI State Sanitary Code as described in the application for Disposal Works Construction Permit No.__. ...... --------- daA----------9/2.7/`7-a.................. A THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... ............? Inspecto r ..........................................C-1- ...............I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................T.aWri.......OF...............Barnatable....................................... No....... ........ FEE...$,5.,00 ................. Disposal Workii T-Lonotrurthitt "Vrr I ftfit Permission is hereby granted__..A... ----12-8---Bishaps---- to Construct or Repair ( x) an Individual Sewagez'Disposal System at No.....116...01a...139on...jLd_...g....W.e.-at...1!jraXM1Q&1hVr_1�------ ...Realtl..................... struction Street as shown on the application for Disposal Works Perm t:d---0 .......... Board oi DATE........ ............................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS