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HomeMy WebLinkAbout0259 OLD TOWN ROAD - Health 269 OLD TOWN,RD.; HYANNIS A= o I. r f I ° i i 0 TOWN OF BARNSTABLE LOCATION Q(8 7c:wN PaAn SEWAGE# a,,) J3 T LLAGE -Pg1 �. ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. CQ3 017) 'Z� SEPTIC TANK CAPACITY, , ZED CtG� r LEACHING FACILITY.(type) �'tST ' 01 X� X�/ (size) Saar NO.OF BEDROOMS OWNER 1 i 1 ca PERMIT DATE: 1 , COMPLIANCE DATE: Separation Distance Between the: �q Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N Feet Private Water Supply Well Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching,�FFacili If any wetlands exist within 300 feet of leaching fa�Ility) ?t' °� Feet FURNISHED BY - � n6 J . r� TOWN OF STABLE k SEWAGE # L JCi'ION :LLAGE is _ASSESSOR'S MAP & L 60 —0 INSTALLER'S NAME UHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Y+ �� Al � � a n� s V ¢J ® M It s __ No. Ct7" 'v Fee '� v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftphration for Disposal *pstem Construction i9Ermit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System .Individual Components Location Address or Lot No. ?579 01& Owner's Name,Address,and Tel.N _ Assessor's Map/Parcel 02(c � � V 0 l eCo Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(4 Other Type of Building No.of Persons p( Showers( !�Cafeterias) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 �� r�iQA�()r Type of S.A.S. ���iTB••t G� ���`125 Description of Soil u A j(z ta-) C?C o Nature of Repairs or Alterations(Answer when applicable) a iei—&r,en '1 gjQsz A-o etc�t�kcc-) flt�a `� c��' Pr�Ac ►► T 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 Enviro tal Co d t to place the system in operation until a Certificate of Compliance has been issued by d of He igned Date /��1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 49 �`�� Date Issued No. C!" v y Fee /��✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'V PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 010plication for 13isposai 6pstem Construction Vertnit f.,. Application for a Permit to Construct( ) Repair(>(� Upgrade( ) Abandon( ) ❑Complete System ,.®,Individual Components Location Address or Lot No. Z 5c1 Q{Cl R6 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel G�i - . 4 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: r Dwelling No.of Bedrooms �+'u� Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons c;� Showers( Vf Cafeteria kl) Other Fixtures DesignTlow(min.required) gpd Design flow provided gpd Plan Date t Nurnberkof sheets Revision Date Title Size of Septic Tank 66 C7. f v-, Type of S.A.S. ' ;� .►�, r jG�� �' Description of Soil 4 t &o k�r f-o QCC,di-x� - r Nature of Repairs or Alterations(Answer when applicable) ;tic. cz�- `j<--ho". c61 r, StZ A CfC,<3M\S Date last inspected: I Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in j accordance with the provisions of Title 5 of the Environmen tal Code-and not to place the system in operation until a Certificate of Compliance has been issued by this-Board of Health. Signed 11 �► Date �� �" Application Approved by Date el �l316 .y Application Disapproved by Date for the following reasons - Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired� Upgraded( ) Abandoned( )by at �VC\a.t U has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No O /9- dated 11 - / t'„h Installer ( C tY�Q� 4--� Designer 1 f� #bedrooms U Approved-design flow gpd The issuance of this permit shall not beconstrued asa guarantee that the system will ion a((sf��designed. Date / J/ Inspector� �! � Pt 7g No. �! �_ ".� A Fee lac) THE COMMONWEALTH OF MASSACHUSETTS T PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal *pstem Construction Permit Permission is hereby granted to Construct( ) pair( Upgrade( ) Abandon( ) System located at9 ,S9 V �r�0 c�.x-, \ 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be corrifleted within three years of the date of this f e` rmit. ' Date `7f Approved by, z , °FtT Town of Barnstable COW 1"P-` %r sta l IdVI'5 blk Regulatory Services Department aft 'ca��" BAMSTABLE, g1 i �$ 6 9. ,m� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0305 May 8, 2018 PERIVOLARAKIS,NICHOLAS & TINA 24 OLIVER ST FRAMINGHAM, MA 01702 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 259 Old Town Road, Hyannis, MA was inspected on 04/12/2018 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Two cesspools are in "poor condition" and "falling apart" per the report. A replacement septic tank is needed. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mai ling\Conditionally Passes Letters\259 Old Town Road Hyannis.doc - �1KET . ° Town of Barnstable • - � AI Rq�TIAi� � • Regulatory. Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-862-4644 ` P ichard Scab Director FAX 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 . Rev. 5111116 DEADLINES TO•REPAIR FAMED.S,YSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) 'An`x"marked in the ❑is the failure criteria and associated repair deadline 60 DAY DEADLM CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe :. o Backup`of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool r ❑Any portion of the SAS,cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well o Any portion-of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis.'(This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single Cesspool Any"conditionally passed systems" (broken cover,relocation of pipe,reloc 'on of a drive'way,clue to H-10 components, etc) -CQfig ( C�ineAs o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) - ❑Leaching facility with standing liquid level at or above the invert pipe`(per Town Code,§360-20 h) : OTHER - Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts DD -1-- Title 5 Official Inspection Form t., 1 hI Subsurface Sewage Disposal System Form Not for Voluntary Assessments M+ 259 Old Town Rd r:y Property Address Tina& Nick Perivolarakis Owner Owner's Name information is Hyannis MA 02601 4-12-18 required for every H y page. City/Town State Zip Code Date of Inspectio'Eli P+� 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. A. General Information 1. Inspector: Shawn Mcelroy " Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs�Further Evaluation by.the Local Approving Authority r 4-12-18 pector'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 Commonwealth of Massachusetts Title 5 official Inspection Form Y'�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 259 Old Town Rd Property Address Tina & Nick Perivolarakis Owner Owner's Name information is required for every Hyannis- MA 02601 4-12-18 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:. ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or In 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "ConditionalPass" 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. r Check the boz 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. I ❑N ❑ ND (Explain below): Cesspools are falling apart. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposol System-Page 2 of 17 Commonwealth of Massachusetts P. Title 5 Official Inspection Form i Ii Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 259 Old Town Rd Property Address Tina & Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) a ❑ 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 ON ❑ ND (Explain below): C). Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1,� System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments r f"+ 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is-equired for every Hyannis MA 02601 4-12-18 cage. 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: r . ❑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 x❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ® 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 El than '/Z day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts fita ;a,. Title 5 Official Inspection Form w:. ' i.; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1-J„ 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 1. ' � - ❑ ® 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. 0 ® 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. I 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 t 3 Title 5 Official Inspection Form ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yi>r' 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town' State Zip Code Date of Inspection C. Checklist I . . 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? ® El 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? 1 ® Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 V t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts r� Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina & Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 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 ® 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2018 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 c Commonwealth of Massachusetts - r' y Title 5 Official Inspection Form ' p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y> 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 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: Owner--pumped within last 2yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ❑ Septic tank,distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ❑ Privy ❑ t 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): 2 cesspools with 2-4x4x4 galleys t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1960's with galleys added in 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): .• Depth below grade: 30"feet Material of construction: ® cast iron r 0.40 PVC , ® other(explain): Orangeburg Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): See cesspools pg 13 Depth 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: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) f ` 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.): y 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 y t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town 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: •,i 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 3 Title 5 Official Inspection Form ii M► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must lie opened)(locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 0, 259 Old Town Rd Property Address Tina & Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2-4x4x4 ❑ 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.): Leaching galleys video inspected and found empty at inspection with no visible signs of failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2-Inline Depth—top of liquid to inlet invert N/A Empty Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 5x5 Materials of construction Block 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 �-r Title 5 Official Inspection Form w., i�I Subsurface Sewage DisposaLSystem Form Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is H annis MA 02601 4-12-18 ` required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Two block cesspools in poor condition and falling apart. 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 a Commonwealth of Massachusetts -,r ,w Title 5 Official Inspection Form �► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina& Nick Perivolarakis Owner Owner's Name information is Hyannis MA 02601 4-12-18 required for every H y ' 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 cl k F D CO l [S4eJ !. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Inl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina&Nick Perivolarakis Owner Owner's Name information is required for every Hyannis MA 02601 4-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope' ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. 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 i ;�z Title 5 Official Inspection Form ! rf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 259 Old Town Rd Property Address Tina&Nick Perivolarakis _ Owner Owner's Name information is Hyannis MA 02601 4-12-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins.doc-rev.6/15 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �� 4 :. �\S� N �� �`� \� , � �� ' � � � � _� C S � �` i i Z rp R, � ' `. , �, O1;````� ��� 1 [3\_ ,,^_``\ w� `\\\ `\ M �� �d � �_ � n JUN. 7.2005 7:20AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.6 f - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y H J TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 259 OLD TOWN RD WEST H'YANNISPORT,MA 02672 Owner's Name: PRELTS Owner's Address: BOX 847 E.GRANBY CONN, Date of Inspection: 1116/00 Name of Inspector:(please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2110 TEATICKET,MA.02536 Telephoge Number: 508-564-6813 FAX 508-564-7270 CERTIFICA J'ION STATEMENT I certify fhat 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: X Passes _ Conditionally Passes _ Needs F er Evaluation by the Local Approving Authority Fails Inspector's Signature: . Date: 11/6100 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 acid 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. Notes and Comments THE SYSTEM PASSES TITLE V 1NPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE YEAR TO PROLONG THE SYSTEWS USEFULL LIFE. ""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 futtiit.under the same or different conditions of use. JUN. 7.2005— 7:20AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.7 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A CERTIFICATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 1116100 Inspection Summary: Check A,B,C,D or E/AL39' YS complete all of Section D A. System Passes: X I have not found aW 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 SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain, n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfittration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain:n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed _ distribution box is leveled or replaced ND explain:n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Boar&of Health): _broken pipe(s)are replaced _obstruction is removed ND explain:n/a JUN. 7.2005— 7:20AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.8 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMRENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 759 OLD TOWN RD VEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 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(i)(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 fall 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 so 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and free from pollution from that facility and the presence of ammonia volatile organic compounds indicates that the well is i 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: n/a z -� JUN. 7.2005 7:21AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.9 -.'Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6100 D. System Failure Criteria applicable to all systems; ections: You must indicate`fires"or"no" for alLins to each of the following p Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or poriding of effluent to the surface of the ground or surface maters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volu a o is f ss th obstructed a swNumber of times X Required pumping more than 4 times in the last year NOMdue to clogged p P ( ) pumped n&. g ground water elevation. _ X Any portion of the SAS,cesspool or privy is below high gr X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well with _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply w no acceptable water quality analysis. [This system passes if the well water analysis,performed 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.) _ _ (Yes9The 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 15,00 gp You must indicate either`yes"or"no"to each of the followid. ng; (The following criteria apply to large systems in addition to the criteria above) Yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 A shall upgrade the system in accordance with 310 CMR 15,304,The system owner should contact the appropriate regional office of the Department. A ----'JUN. 7.2005 7:21AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.10 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTSON SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ORM PART B CHECKLIST Property Address: 259 OLD TOWN"WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection'. 1116100 Check if the following have been done,You must indicate"yes"or"no"as to each of the following: Yes No g _ pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out.in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? g _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? .X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the%cility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. g _ Determined in the field(if y of the failure.criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)( )] i JUN. 7.2005 7:22AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.11 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION s Property Address, 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 1116100 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): S Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 4 of bedrooms):550 Number of current residents: 0 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use:(yes or no):YES Water meter readings,if available(last 2 years usage(gpd)):n/a Sump pump(yes or no):NO Last date of occupancy:n/a COMMERCIAL/INDUSTRIAL Type of establishment:n/a Design flow15.203 :n/a(based on 310 CMR ) gPd Basis of design flow(seats/persons/sgft,etc.):n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings,if available:n/a Last date of occupancy/use:n/a OTHER(describe):n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO -If yes,volume pumped:n/agallons--How was quantity pumped determined?n/a Reason for pumping:n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy . _Shared system(yes or no)(ifyes,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 DPP approval Other(describe): Na Approximate age of all components,date installed(if known)and source of information; 1964 ORIGINAL W/RE,PAM IN 86 Were sewage odors detected when arriving at the site(yes or no):NO �S JUN. 7.2005 7:22AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.12 -,Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 BUILDING SEWER(locate on site plan) Depth below grade:12" Materials of construction: cast iron _40 PVC Xother(explain):ORANGEBURG Distance from private water supply well or suction line:n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction:Xconcrete metal fiberglass_polyethylene other(explain)n/a If tank is metal list age:n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions:5'X 5'BLOCK CESSPOOL" Sludge depth:n/a Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:0" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined:MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.THE CESSPOOL WAS EMPTY AT THE TIME OF INSPECTION,RECOMMEND PUMPING EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:—(locate on site plan) Depth below grade:n/a Material of construction: concrete_metal fiberglass_polyethylene_other(explain):n/a Dimensions:n/a .Scum thickness., n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle:n/a Date of last pumping:n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 JUN. 7.2005 7:23AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.13 • Pages of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHI'rLTS Date of Inspection: 11/6/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade:n/a Material of construction: concrete metal_fiberglass-polyethylene_other(explain):n/a Dimensions:n/a Capacity:n/a gallons Design Flow:n/a gaIlons/day Alarm present(yes or no): N/A Alarm level;N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:n/a Comments(note if box is level and distribution to'outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no);NO Alarms in working order(yes or no):NO er,condition of pumps and appurtenances,etc.): Comments(note condition of pump chamb n/a I R �JUN. 7.2005 7:23RM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.14 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: 0 GALLIES W/3'OF STONE leaching galleries, number: 2 n/a leaching trenches, number, length: nla leaching fields, number: n/a 5'X T BLOCK CESSPOOL overflow cesspool,,number: q R/a innovative/alternative system Type/name of technology: nla Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE GALLIES APPEAR TO FUCNTIONING PROPERLY.THEY HAVE BEEN 3/4 FULL.THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE OVERFLOW WAS EMPTY AT THE TIME OF INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer:n/a Depth of scum layer:n/a Dimensions of cesspool:n/a Materials of construction:n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction:n/a Dimensions:n/a Depth of solids:n/a Comments(note condition of soil,signs.of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 0 JUN. 7.2005 7:23AM CARDIOUASC. LAD CHILDREN'S HOSP. NO.527 P.15 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 1116100 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 4b it 4Aa1y /rD AA 3y Y in JUN. 7.2005 7:23AM CARDIOVASC. LAB CHILDREN'S HOSP. NO.527 P.16 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 1116100 SITE EXAM _Slope Surface water r Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation! NO Obtained from system design plans on record-If checked,date of design plan reviewed:n/a NO Observed site(abutting property/observation hole within ISO feet of SAS) NO Checked with local Board of Health-explain:n/a NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-12+FEET 11 iI r I pE *Mla PARCEL M MAP N0.—=�--� S E 1N A C E vttLACE E ` A Q p ft E S 5 LL S N WOE S UILDEIt Off' �wME �a w ID E p El11�11 A 1 C� . oMpttA � CE ' tSsUEp I DATE C . d 5 1 __ , Z T'd ZZS'ON 'dSOH S,WMIQ-IHO SHE 'OSUAOI G'Jd0 wuv2:Z S003'Z 'wnf 1 1 . �'�- ' ��_�.._. � . . . . .. �_,i �. f���.�r�r;;,,fir:, ;•,�',�� �� . F',f�i oiw n t 1 10, Sew + f ' i , • h � f Co c i I 4 � (1V r UJ C G/h2-10 . . G 23 ............... ...... Y ti. .1 Cl 3 - <;' x :>' Carok M Smith 7 Sad& Dfive - Ea st r , CT 06026 Date __ NC Vem ber To: Orn /41 cl<ea.n n - Sublect /a(, O n I , ri 4P�ctf , 3 � �'P•'�- _ �ea_sin !"0 rr�_ ; _ FAX IKM s- 7 33 Lf 4jn62 o r a 25 OJ Tow ' N iM fDearr. L ,-, e is a= r f- s N .. W . Q+ � N � W OD N y r '0 Signets m r F.. Town of Barnstable Health Inspector of�roiy Off ce Hours yP` Regulatory Services 8:30—9:30 ' Thomas F.Geiler,Director 1:00—2:00 ���uvsrnsc,E. 16p,�� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE 1. General Information: Size-of Property: Address: �9 N, Ma Parcel Name: / ��l�d��Q�/ Phone #: Q 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes, how many? Q 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label . each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO e�dwe}Ii�g�s conne�c[ed t er,skip�questLons`�4 tltro�,g��9�belnw,, fr 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contnbution to public supply wells? 5: Is the dwelling connected to an ONSITE WELL or to PUBLIC WATE 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? aedrooins. 7. Were any building permits obtained for construction of additional bedrooms? YES �or ENO cn co .8. Is there an engineered septic system plan.on file at the Health Division? C) YES or ENO 9. Has the septic system been inspected by a DEP certified inspector within the last.two years. YES or ---iNO �pl FOR OFFIC)aooms USE e Public Health Division has no objection to at this property. 6J' 1 (1 5 Special Conditions: i - �QQs Signed: — Date: v O;/health/wpfzles/amnestyapp COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a Y Y Y F A t .y r• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner's Name: PHELTS Owner's Address: BOX 847 E.GRANBY CONN. " Date of Inspection: 11/6/00 i r. Name of Inspector: (please print),)-�. JOHN GRACI 0,1, Company Name: `SEPTIC INSPECTIONS �1 e Mailing Address: P.O..'BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 ? CERTIFICATION STATEMENT I certify Chat 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 ofjitle 5(310 CMR 15.000). The system: ; X Passes _ Conditionally Passes _ Needs F er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 11/6/00 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 shalif,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. Notes and Comments `iX THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. Title 5 ImmPrtinn Fnrm 6/1';OnO I 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) y , Property Address: 259 OLD TOWN RD'.WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: =P X I have not found any information,which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statem,.nts. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a =r n/a Observation of sewage backup,or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruct _ ion is removed +distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board'of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a u,.rl is Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 i, C. Further Evaluation is Requir4by 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 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: E, a _ 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. . v _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other:. n/a 95, `i ,I l• '.I k j. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f CERTIFICATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool {`"' _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nla. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a.cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 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.] (Yes N�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. t` E. Large Systems: f'tit 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 must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) u: yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of aptributary to a surface drinking water supply X the system is located in a nitrogen�sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped jl 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 lies 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. t d Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 259 OLD TOWN RD-WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 Check if the following have been done.;You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank ma;Ales'uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? e � z t ` The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the.failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] t 5 Page 6 of I I Y I.�Z OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): YES ' . Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a a . Design flow(based on 310 CMR 15.203,): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a , GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil"absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ` _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1964 ORIGINAL W/REPAIR IN 86 Were sewage odors detected when arriving at the site(yes or no): NO C Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron _40 PVC Xother(explain):ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 5'X 5' BLOCK CESSPOOL" Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to`bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.THE CESSPOOL WAS EMPTY AT THE TIME OF INSPECTION.RECOMMEND PUMPING EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) 4 Depth below grade: n/a "`" Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a E, f- i! t�El;i i 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity:n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO `^` Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a i t, i R Page,9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: 0 GALLIES W/Y OF STONE leaching galleries, number: 2 n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 5'X 5' BLOCK CESSPOOL overflow cesspool, number: n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE GALLIES APPEAR TO FUCNTIONING PROPERLY.THEY HAVE BEEN 3/4 FULL.THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE OVERFLOW WAS EMPTY AT THE TIME OF INSPECTION. CESSPOOLS: (cesspool must Wliumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a y PRIVY: (locate on site plan) °Sp, ,7 Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a Q Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 r.k SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1f D e u A ,4A a1 L Ab aS q 0. y if in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 259 OLD TOWN RD WEST HYANNISPORT,MA 02672 Owner: PHELTS Date of Inspection: 11/6/00 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators;installers-(attach documentation) YES Accessed USGS database-explain:n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET 4 �+ 1' k} 11 ASSESSOR'S MAP NO. PARCEL C2 O d `ION S E W A G E PE RMIT NO. OD 7-cjw� 1V-1LLAG'E INS L'L 'S NAME i ADDRESS I U I L D E R OR OWNER FS1r��✓`e� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED /t,-& 0 . � z o E N L^^ N r al z ,e I TOW O B . TABLE LQCA��'LON,. o2SL� �Id o -✓'►.:, SEWAGE;# YtGi,AG� �7 .I/./I 7 ASSESSOR'ss. r#P�P 3NSTA3rI.>R M ' PRONE {1 S8M. C. TANK Cf�ACTfY' kS e�f,tea - LEACfiIN FAC[Ll 1't0 QF'SBI3RaOMS - 13t3Y1.DEYt OR OWi�tER PEItA TDATI: aA PI.IAIdCF.-- ►TE:' Saparanon Distance Betw�n`�c Maximum Adjasted Cnoundwter Table to the Bottom gf Leaching Facility Feet Pnvae t�►atarSupply We11 andLeacng Facility (I€:aaY�areiis exist on site or..ainthin?0D.feet of leaclnng fa Edge of V�letland and I.eaclung l"acxllty(Ff any cvetlarids exi t withea3(l{)`feetQft tuns fa ') '' Feet Furnished.by. ,Fa coo 3 ' n Dp r r ' Seel - � C-3 - /Ir �D-3 - y Ze No ..... � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � W..............oF...-..—sx,.•✓..w--�'"`.e... Appliratinn for Disposal Works Tonstruktinn Upfrutit Application is hereby made for a Permit'to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..._.{. .Gl_.....�'?.l.` .. .!^�..._. Q-••........... ...........�4 fc�. H-�.-I.................................................. Locafo -Address t rr�� -or Lob No. ..............L...2�'Lh. ........... .................•.....- n �--� --••--------•---- -----------------.----- Ow er W �y Address ••---...------ C\ ..� 'aµ vacs -1" fJ ............... Installer Address Type of Building ;3 Size Lot................ Sq. feet �-. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PPa4 Other—Type of Building ............................ No. of persons-.--_,______----•-__-__-___- Showers ( ) — Cafeteria ( ) Other fixtures --------- ......................... Design Flow.._.....S.C�._.......................gallons per person per day. Total daily flow......... ..................gallons. f W Septic Tank—Liquid ca.pa ity............gallons Irength................ Width.......`....... Diameter........:....... Depth................ x Disposal Trench—No.................... Width....V.0.__.._... Total Length__....W..1..... Total leaching area....................sq. ft. 3 Seepage Pit No.----•--.....-_____-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch ' Depth of Test Pit.................... Depth to,ground water........................ a -------------------------------- ----- •............ -......... •---------- -......... -------------------- •-------------..--------------- ••----- •.............. -•-- 0 Description of Soil....................................................................................................................-----•------•---.......------•-•...............•----- U -------------------- ---------- -------------------------- ------------------- ------------------------------------ = W x --•----------•----------•--•• -------•••--•--•••-••------••-•-•-------------------•---•...••--•••-------••-•-------•---•----------•----•-•••--•----------•----- ............. .. U Nature of Repairs r Alterations—Answer when applicable___--.deb__lp.........a.....l�-o.�. ...... � ............ •....._ l.�1,�`'C--- Qc?.......4?�..Jnsi _ _.. .1S rays.-------•-•----------- ---------•---------•--............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 1TL i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of om lian p C as - ed by the and of P i� C/ Signed. . • -- ------------ -----••-:--••-- -------------• ''�� d-!Q /Dat Application Approved By------------- ----- - ---•--------- .................................... •--•- --•-�•- ......... ....-- Date Application Disapproved for the following reasons-..................................................................:............................................ . ..-•-•--••--•---••--•-•-•.....................�--�...............------....------....---=•--•----------..................---------------••-•-----..................................................... No............. C� f •---..,---- -------------�_ Issued_........_..._._..---------•----•--•---....Date...... Date CID Fss.. NcE THE COMMONWEALTH OF/MASSACHUSETTS BOARD OF �H EALTH � M w..............oF..... ..,, Applirtt#ion for i fro ttl oxk C��an #r r# ogt� rani# t Application is hereby made for a Permit to;'Construct ( ) or Repair ( } an Individual Sewage'Disposal System at Locat'o -Address F j or Lot No. r .....,. Owner / Address --- W - C" +� ..............:.Jr..:....._..---•---•------•-•-- --'�---�--•-C ............. / J `T�LA ba..r4 L:.1' f/• ........._..... o.... e �...................... •--•••.........a Installer Address Type of Building 1 Size Lot............................Sq. feet r , Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.......i........._......... Showers ( ) — Cafeteria ( ) dOther fixtures = ----.--� •-------------•-------...----------.----------------.-.--------•---- W Design Flow........7Z'_N.Z.....................gallons per person per day. Total daily flow.........;��'s'..................gallon. WSeptic Tank—Liquid capacity............gallons If ength................ Width................ Diameter................ Depth................ x Disposal Trench—No........I............ Width...._ ......... Total Length_....ti Q 1..... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Dept11 below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Nest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit__._............._._ Depth to ground water........................ fYi ------------------------------------------------------------- ....... .------- . ------------ •----...-•-•---•---------I.--------- ..---------------- Descriptionof Soil -•---------------------•-••----------------------....-------•--------...--------------------------.......................................................... V .---------------•--...•-•-••----••----••---•--.......•.................................................................................................................................................. W x ------------------ v Nature of Repairs Alterations—Answer when applicable---------�b-tt�__....._a.....41X_ .......-�J R-eL'� ............. -----• t `dam-------- T v-----..� �.nV•vc ...Cx� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'll, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianee`h\een-issued by the oard of health. I _- Signed_.. S -- �S �DattE' Application Approved By.........................: -���. Date Application Disapproved for the following reasons--------------------------------•---------------------•--------•------. ....................................... ��- ..............................................----------•---••--....--•-•-•----...............----.............. ............. Date PermitNo............ .. ram.. Issued..................................................... Date __........_..-e.._.—_»..,-_� ._..�..,...—�._.._.-w..—.�....a;ie`---.�..,........�..�.....�_......_..�..—.-...—..__.__......-.....�_,..__...�__._.�.�,—_.._.-.tee._---._s.._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rJt�lj:v ......OF......�7�! .✓..Y�- � �:' ...................................... Cnrr#ifiratr of Tompliatta THIS 1,S-Z0 CER -F 3'• hzkt the Individual Sewage Disposal System constructed ( ) or Repaired by.................. .....k,.�...........�-.� r.�.� f....... ........(_ Ins' er --.......I'll--------------------------------...-..--------------------------.--------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as c 'bed rin the application for Disposal Works Construction Permit No.__.���- ----__- ... dated............. /.. :.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRUE® AS A GUARA TE THAT-THE" SYSTEM WILL--FUNCTION SATISFACTORY. DATE................ � .......... `�...................•---•-•--•••. Inspector..••---•�• = THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH •--�� -"- e?�a . ...........OF.......�d�. ,�...1c..E 4 l Q t o Vrk ((onstrur#ion "rani# Permission is hereby granted = g --•-•-• to Construct ( ) or Repair (G)—a,&4ndividual Sewage Dis osal>System -m. atNo.. .'��= .._�-Wit_ i v - ............................................................... .47 Street * as shown on the application for Disposal Works Construction Permit N _�(.Q..1/�_., Dated........ y , _�_________ •-----DATEBoard of t[cCitth cb�� �!1 7 gZ0