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0077 OLD YARMOUTH ROAD - Health
= ` 77 OLD YARMOUTH ROAD,HYAN1vIS A= 344 053 [ � 1• 1 i t � a � COMMONWEALTH OF MASSACHUSETTS W Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Property Information: MAP 344—PARC 53 77 OLD YARMOUTH ROAD — HYANNIS, MA 02601' Property Address PURITAN CLOTHING Owner's Name 400 MAIN STREET Owner's Address HYANNIS MA 02601 City/Town State Zip Code DECEMBER 8, 2006 Date 2. Inspector: JAMES D. SEARS Name of Inspector A & B CANCO Company Name 350 MAIN STREET Company Address WEST YARMOUTH MA 02673 CID t City/Town State Zip Code 1773 =' 508-775-2800 � � . Telephone Number r B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the informati n reported Na below is true, accurate and complete as of the time of the inspection. The inspection was performed base on my training co and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP pprovedc--) I system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: 4 [� ® Passes ❑ Conditionally Passes ® Fails ® N ds Further Evaluation by th Local Approving Authority In tor'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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 f COMMONWEALTH OF MASSACHUSETTS is d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 77 OLD YARMOUTH ROAD Owner's Address HYAN N IS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection 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. l Comments: B) System Conditionally Passes: N/A ® 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 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS W Title 5 Official Inspection Form 9 tl Not for Voluntary Assessments '1M SJev Subsurface Sewage Disposal System Form B. Certification (cont.) 77 OLD YARMOUTH ROAD Owner's Address HYAN N I S MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection B) System Conditionally Passes (cont.): 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): Elbroken 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: C) Further Evaluation is Required by the Board of Health: NIA ® 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 r COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection. Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form j B. Certification (cont.) 77 OLD YARMOUTH ROAD Owner's Address HYANNIS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A 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 that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 F COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form 9 tl Not for Voluntary Assessments l�Ar SJev Subsurface Sewage Disposal System Form B. Certification (cont.) 77 OLD YARMOUTH ROAD Owner's Address HYANNIS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A 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 pit is less than 6" below invert or available volume is less than '/2 day flow ® ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ® ® Any portion of the SAS, cesspool or privy is below high ground surface water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® FN—/A7 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.] YES No ® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. Yes No ® ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. I Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS c Title 5 Official Inspection Form Not for Voluntary Assessments p^ Vev Subsurface Sewage Disposal System Form B. Certification (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection 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. N/A For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ® the system is within 400 feet of a surface drinking water supply ® ® the system is within 200 feet of a tributary to a surface drinking water supply ® ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form o Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 77 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 Cityrrown State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® Pumping information was provided by the owner, occupant, or Board of Health ® ® Were any of the system components pumped out in the previous two weeks? ® ® Has the system received normal flows in the previous two week period? ® ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ® Was the facility or dwelling inspected for signs of sewage back up? ® Was the site inspected for signs of break out? ® ® Were all system components, including the SAS, located on site? ® ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction dimensions, depth of liquid, depth of sludge and depth of scum? ® ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ® Existing information. For example, a plan at the Board of Health. ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS u w Title 5 Official Inspection Form d e� Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 77 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual).- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes ® No Laundry system inspected? 0 Yes 0 No Seasonal use? 0 Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ® Yes ® No Last date of occupancy: Commercial/Industrial Flow Conditions: J Type of Establishment: ONE BEDROOM APARTMENT OFFICE-WAREHOUSE BUILDING Design flow(based on 310 CMR 15.203): 197 GPD Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) (1)OCCUPANT—29'X 59.5' Grease trap present? 0 Yes ® No Industrial waste holding tank present? 0 Yes ® No Non-sanitary waste discharged to the Title 5 system? 0 Yes ® No Water meter readings if available: N/A Last date of occupancy/use: PRESENT Date =-• Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 f COMMONWEALTH OF MASSACHUSETTS u w Title 5 Official Inspection Form d Not for Voluntary Assessments p� yev Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection General Information Pumping Records: Source of Information: N/A Was system pumped as part of the inspection? ® Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ® Privy ® Shared system (yes or no)(if yes, attach previous inspection records, if any) ® Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ® Tight tank. Attach a copy of the DEP approval. ® Other(describe): Approximate age of all components, date installed (if known)and source of information: 1980 Were sewage odors detected when arriving at the site? Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS R Title 5 official Inspection Fora a Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection 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.): PVC GOOD Septic Tank(locate on site plan): ✓ 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: 1000-GAL H-20 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum Thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 181, How were dimensions determined? ASBUILT—TAPE—SLUDGE JUDGE Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS ro Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYANNIS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK AT WORKING LEVEL, STEEL COVERS AT GRADE. i INLET TEE — OUTLET TEE. NO SIGN OF LEAKAGE OR OVER LOADING. 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 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): N/A Depth below grade: Material of construction: ® concrete ® metal ® fiberglass ® polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS N Title 5 Official Inspection Form 7 tl Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Tight or Holding Tank (cont.) N/A 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 a copy of current pumping contract(required). Is copy attached? ® Yes ® No Distribution Box (if present must be opened) (locate on site plan): ./ Depth of liquid level above outlet invert 0 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.): D-BOX 24" X 24" —28" BELOW GRADE. ONE LINE IN — ONE LINE OUT. BOX IS CLEAN AND SOLID. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 f COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form r Not for Voluntary Assessments p^ yev Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): I Soil Absorption System (SAS) (locate on site plan, excavation not required): ./ If SAS not located, explain why: Type: ® leaching pits number: 1 ® 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.)- LEACHING H-20 PRE CAST PIT AT 32" BELOW GRADE WITH STEEL COVER AT GRADE. STAIN LINE AT 10"- NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ® Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 • COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form a• Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection 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. I f l� of c Title Official Inspection Form:Subsurface Sewage Disposal System page 15 of 16 COMMONWEALTH OF MASSACHUSETTS w v Title 5 Official Inspection Form d r Not for Voluntary Assessments 41 y0y Subsurface Sewage Disposal System Form D. System Information (cont.) 77 OLD YARMOUTH ROAD Property Address HYANNIS MA 02601 City/Town State Zip Code PURITAN CLOTHING Owner's Name DECEMBER 8, 2006 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30' + 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 BARNSTABLE TOPOGRAPHY 30' + TO GROUND WATER. BOTTOM OF PIT AT 9'. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 *� APPLICATION FOR SITE PLAIN REVIEW LOCATION Business Name: 77 Old Yarmouth Realty, LLC Subdivision Plan Assessor's Map# 344 Parcel# 33 ANR Plan Property Address: 77 Old Yarmouth Road, Hyannis, Site Plan MA OWNER OF PROPERTY APPLICANT Name: 77 Old Yarmouth Realty, LLC Name: 77 ar ou ea Address: 408 Main Street Address: Hyannis, MA Phone: Phone: Fax: Fax: ARCHITECT/DEVELOPER/CONTRACTOR/ENGINEER AGENT/ATTORN Y � ry n n ,� Name: Dan Ojala, Down Cape Engineering Name: Pat ck M. tar \vW 11►�I�{7� Address: 939 Main Street Address: Nutter, McClennen&Fish, LLP Yarmouth, MA 02675 PO Box 1630, Hyannis, MA 02601 Phone: 508-362-4541 Phone: 508-790-5407 Fax: 508-362-9880 Fax: 508-771-8079 STORAGE TANKS(HAZ MAT/FUEL OR WASTE OIL) ZONING DISTRICT CLASSIFICATION Existing Proposed 0 District B 0verlay(s) WP Number unknown Number Size Size Lot Area —4,850 sf Sq. Ft. ---0.11.Ac. Above Ground Above Ground Fire District Hyannis Underground Underground Setbacks (ft.) Contents Contents Front —32 Side —4/ --17 Rear - 2 Number of Buildings Existing 1 Proposed 0 Demolition 0 DEC 2 3 2003 Utilities AP j'�\ E TOTAL FLOOR AREA BY USE Sewer- ❑ Public P a%oze, Q00gal I Existing(sq. ft.) Proposed(sq. ft.) Water- ® Public a Basement Electric ® Aerial ❑ Underground Residential -- 444 sf Gas- ❑ Natural ❑ Propane (UNKNOWN) Restaurant Grease Trap- ❑ Size gal Retail Sewage Daily Flow * 174 gpd(Note: See BOH Office Variance) Medical Office PARKING SPACES CURB CUTS Storage — 2,612 sf Required 5 Existing 1 Wholesale(specify) Provided 5 Proposed 0 Institutional (specify) On-Site 5 To Close 0 Industrial (specify) Off-Site 0 Totals 1 All Other Uses On Site Handicapped 0 Gross Floor Area — 3,056 sf *GP or WP areas restrict wastewater discharge to 330 gallons per acre per day into on-site system. Old Mng's Highway Regional Historic District File# Approved? ❑Yes ® No Hyannis Main. St./Waterfront Historic District File# Approved? ❑Yes ® No Listed in National and/or State Register of Historic Places? ❑Yes ® No Previous Site Plan Review File# Approved? ❑Yes ❑ No Previous Zoning Board of Appeals File# Approved? ❑Yes ❑ No Is the site located in a Flood Area(Section 3-5.1) ❑Yes ® No In Area of Critical Environmental Concern? ❑Yes ® No Is the Project within 100' of Wetland Resource Area? ❑Yes ® No Site sketch- informal presentation ®Yes ❑ No Site Plan prepared, wet stamped and signed by a Registered PE and/or PLS. ®Yes ❑ No Parking and Traffic Circulation Plan ®Yes ❑ No Landscape Plan and Lighting Plan ®Yes ❑ No ** Drainage Plan with calculations and Utility Plan ❑Yes ❑ No Building Plans, (all floor plans, elevations and cross sections) ®Yes ❑ No*** *See Notation on Plan. **To the extent same is shown on Plan. *** Floor Plans only. Note that all signage must be approved by Code Enforcement Officer at the Building Department Lot area in sq.ft. - 4,850 sq. ft. Total Building(s)footprint - 1,725.5 sq. ft. Maximum Lot Coverage as % of.Lot - 35.5% % GROUND WATER PROTECTION OVERLAY DISTRICT.REQUIREMENTS: DISTRICT: WP Lot Coverage (%) Required 50% Proposed p 37% Site Clearing Required 30% natural Proposed Existing level of development has virtually no natural vegetation. PRINCIPAL BUILDING Accessory Building (s) ❑ Yes ® No Number of floors 2 Height -22 ft. Number of floors Height: ft. FLOOR AREA: FLOOR AREA: Basement sq. Second 1725.5 sq Basement sq. ft. Second sq. ft. ft. ft First -- 1725.5 sq. Attic sq. ft. First sq. ft. Attic sq. ft. ft. _ Other(Specify) sq. ft Please provide a brief narrative description of your proposed project. The Applicant proposes to remodel the interior of an existing structure In particular, the Applicant proposes to move the existing non-conforming 2 bedroom 2nd story apartment to the first floor and to convert the apartment into a one-bedroom apartment. The remaining area will be utilized for long term storage associated with the Applicant's clothing store, Puritan Clothing, located on Main Street in Hyannis The apartment will likely be used by an employee of Puritan Clothing. I assert that ave I pleted(or caused to be completed)this page and the Site Plan Review Application and that, to the best o owledge th ' ormation submitted here is true. IQZ-g0 Patrick M. Butler, Attorney for Applicant Date PRINTED NAME OF APPLICANT 1283259.1 `i I ;I: 0P45" -Tb '5e%-Os.J 1. '6 i I;, DN j DN MC--Z-LANtIJE S7'oiZAGC i 1S'3' KEYt -- = new UPPER LEVEL demising 929 sq' Mezzanlne 400 sq' above apt, l' v II � I k 'IIi"it � k 1TlNC1J IL 7 UP DN i 0 ,�Aw ITT 59'6' GROUND LEVEL 77 Old Yarmouth Rd., Hyannis, MA FLOOR PLANS new, demising 1,283 sq' Storage 9/2/03 1 L.Grice SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' ra I a y- DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indlcate Y—yea N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Backup of.Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required.pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PAT D - CERTIFICATION INSPECTOR. . ROBERT J.BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY:;: BQRTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,"ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER;FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: /I`HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTROR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN=THE:"FAILURE,CRITERIA",SECTION OF THIS FORM. .rry I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15 303."THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM INSPECTORS SIGNATURE: DATE ORIGINAL TO SYSTEM OWNER,`COPIES:BUYER(II applicable),APPROVING AUTHORITY Nutter 7'OW fOF BAR _ D 7 Patrick M. But er, Direct Line: 508-790-5407 Fax: 508-771-8079 E-mail: pbutler@nutter.com August 27, 2003 #104889-1 Thomas A. McKean Board of Health Town of Barnstable 200 Main Street Hyannis, MA 02601 Re: 77 Old Yarmouth Road, Hyannis, MA Assessors' Map 344, Parcel 53 Dear Tom: Thank you very much for taking the time to meet with Dan Ojala and me last week regarding the above matter. I enclose a copy of the correspondence dated December 18, 1985 which''confirms that the allowed septic flow for the subject property is 197 gallons per day. As we discussed, it is the intention of the new owners to utilize the property for a one bedroom apartment on the first floor and the balance of the property is to be utilized for storage associated with the operation of Puritan Clothing Company. We anticipate that approximately 348 square feet will be utilized for apartment use with the balance of the property to be utilized for storage. Dan Ojala will be providing you with calculations associated with that use which will conform with the 197 gallon per day limit. Thank you for your assistance and cooperation in t ' matter. Sin er o s, Pa ck M. ut er PMB:cam cc: Down Cape Engineering 77 Old Yarmouth Realty LLC 1250478.1 s P j }T , a Nutter McClennen & Fish LLP ■ Attorneys at Law 1513 lyannough Road, P.O. Box 1630 ■ Hyannis, MA 02601-1630 ■ 508-790-5400 ■ Fax: 508-771-8079 ■ www.nutter com December 18, 1985 Mr. Richard A. Landry 11 Prince Avenue Marstons Mills. MA. 02648 Dear Mr. Landry$ " You are granted a variance ftom the Interim Ground Water Protection Regulation limiting daily sewage flow to 330 gallons, per acre, in certain zones of contribution. The location of the variance is 'Old Yarmouth Road, Hyannis, Assessor's Map No. 344. Lot 53. The following conditions apply$ (1) The system must be installed in strict accordance with the engineering plan submitted. (2) The designing engineer must be on site and supervise construction of the septic system and certify in writing to the Board of Health that his design has been strictly adhered to prior to the issuance of a Certificate of Compliance. This variance is granted because it is a replacement of a three bedroom house with a small office building resulting in a reduction of the (tally sewage flow from 330 gallons to 197 gallons per day. Ve trul ours, o filids Chairman BOARD OF HEALTH TOWN OF BARNSTABLE JMK/mm I Tile rp� TOWN OF BARNSTABLE OFFICE OF . BJH39T�S, i bAS.. BOARD OF HEALTH pp i639• � Q MAY k' 387 MAIN STREET Hl"ANNIS, MASS. 02601 March 27, 1989 Mr. Joseph DaLuz Building Commissioner Town of Barnstable Dear Mr. DaLuz: I was informed that an automobile washing, services, and repair establishment d/b/a Elegante' Enterprises, previously located at 77 Old Yarmouth Road, Hyannis, listed as Parcel 53, on Assessor's map. 344 has now moved to a building at the end of Joaquim Road, Hyannis. The facility does not have a Groundwater Discharge Permit from the Department of Environmental Quality Engineering. A facility such as automobile; washing, service, and repair establishment contradicts what is allowed under the present Town Zoning Regulations. Please remove this type of business from the building if they are in violation of any Zoning Bylaw. Sinc rely yours, Thomas A. McKean Director of Public Health TM/bs r TOWN OF BARNSTABLE ypF TH E raw OFFICE OF i HAEb9TeHLE i BOARD. OF HEALTH MA08. _ 90O i639 ,o 387 MAIN STREET �1ampYk� HYANNIS, MASS. 02601 December 12, 1988 f Mr. Kevin Melkonian � Elegant Enterprises 77 Old Yarmouth Road Hyannis, Ma 02601 1 Dear Mr. Melkonian: We recently received a complaint that an automobile washing, services, and repair establishment is located at 77 Old Yarmouth Road, Hyannis, listed as Parcel 53, on Assessor's Map 344. We also received water meter readings from the Barnstable Water Company. You have been discharging 880 gallons per day on this 0.11 acre lot located in a critical zone of contribution to public water supply wells. Also, you do not have a Groundwater Discharge Permit from the Department of Environmental Quality Engineering. You are hereby officially notified that the variance granted to Richard Landry, previous owner of the property, by the Board of Health in it's approval dated December 18, 1985, states that the building is a "replacement of a three bedroom house with a small office building." A facility such as an automobile washing, service, and repair establishment contradicts the proposal to the Board. You are directed to cease and desist any washing, service, and repair of automobiles at this property within twenty-four (24) hours of receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days of receipt of this notice. Sin erely you , Thomas McKean Director of Public Health TM/bs Copy: Selectmen Chairman, Board of Health Joe Daluz enclosure TOWN OF BARNSTABLE CF YN E Taw , OFFICE OF 3"ISTAMBOARD OF HEALTH '00 i639•"�� 367 MAIN STREET HYANNIS, MASS. 02601 September 3, 1987 Mr. Joseph Daluz Building Commissioner A building permit and sewage disposal permit for property at 77 Yarmouth Road, Hyannis , owned by Mr. Richard Landry was approved for office use only, in December of 1985 . A variance from the Board of Health Interim Groundwater use ond aver Protection Regulation was granted for this This building now contains two bays , and it appears that it is to be sold or. leased to a rustproofIng/car detailing ✓✓✓ business . This building was never approved for such use, because it is very close to the public supply wells . Please do not issue the occupancy permit or allow. anyone to use the building except for the approved office use , and clearance from the Board of Health. Your cooperation in this matter is essential in protecting our public supply wells . Very Truly Yours, hn M� Kel irector o ublic Health cc:Chairman Board of Selectman I r O COMMONWEALTH OF MASSACHUSETTS ExI,CUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DI+;1'AR1'IVIENT OF ENVIRONMENTAL PROTECTION !tea ..,, a e�t;EI0/EL e FEB 112003 t TOWN OF BARNSTAL. HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM.-- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 3�1��✓®�� Owner's Name: FI,:ED GOLENSKI Owner's Address: BOX 135 E. SANDWICH MA. 02537 Date of inspection: 1/14/03 Namc uf Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS;_-_j�j1CJ Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accc:rate and complete as of the time of the inspection. The inspection was performed based on my training and experien'.e 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). "rile system: X Passes _ ConditionallyjPasses _ Needs Fur 11 t(er Evaluation by the Local Approving Authority Fails / Inspector's Signature: ! Date: 1/1.4/03 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP) !thin ction. If the system is a shared system or has a design (low of 10,000 gpd or greater,the 30 days of completing this inspe inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should br 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 INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL 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. fitly Inc,irrtion Form (,/I�/-,nnn Page,2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass 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 Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page,3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 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 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 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 PageA of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 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 ''/z 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/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 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 D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d Page.5 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 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 manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For 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)] 5 Page.6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedr s(actual): n/a DESIGN flow based on 310 CMR 15.203 (for mple: 110 gpd x#of bedrooms): 0 Number of current residents: n/a Does residence have a garbage er(yes or no): NO Is laundry on a separate se e system(yes or no): NO [if yes separate inspection required] Laundry system inspe (yes or no): NO Seasonal use: (ye r no): NO Water meter dings, if available(last 2 years usage(gpd)): n/a Sump pu (yes or no): NO Last e of occupancy: n/a COMMERCIAL/INDUSTRIAL Cam- �eCiC�t�C. �� Type of establishment: WAREHOUSE-32' X 36' J Design flow(based on 310 CMR 15.203): n/agpd (1 `�ci� cc) Basis of design flow(seats/persons/sgft,etc.): n/a \\ ✓ j.� Grease trap present(yes or no): NO � `�� d�(Do Industrial waste holding tank present(yes or no): NO a 06 Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a O C L�JiCr Last date of occupancy/use: n/a OTHER(describe): n/a �Lc�1 C 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: 1976 j c� Were sewage odors detected when arriving at the site(yes or no): NO f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is a¢e confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS ' Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: ui ; 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.): SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL 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 Page 8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 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: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. 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 R r Pag~9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD HYANN.IS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 600 GALLON 6' X 4' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a 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 LEACH PIT`:,APPEA16TO BE STRUCTURALLLY SOUND AND FUNCTIONING PROPERLY. PIT; SHOW NO SIGNS OF FAILURE. THE PIT HAD TIN AT THE TIME OF THE 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 4 Page,10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert) Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of inspection: 1/14/03 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. I.A Ac �i FA 0 gC a 1 to Page41 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD HYANNIS 02601 Owner: FRED GOLENSKI Date of Inspection: 1/14/03 SITE LRAM _Slope _Surface water _Check cellar Shallow wells Estimatcd depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systerrl design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water.elevation: I IAND AUGER- 12+FT. I II TOWN OF BARNSTABLE OMPLrANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops ' K unsatisfactory- 4.Manufacturers COMPANY WV_4� "s 21 (see"Orders") 5.Retail Stores V1 �, 6.Fuel Suppliers ADDRESS 2'7 0 Zee ew m �/ � S: 7.Miscellaneous Ao��-,�A"r QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Drums R�� e - IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers 17 Miscellaneous: DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply '7�?Z Z ' O Town Sewer Publicv O On-site Private- c 3. Indoor Floor Drains YES NO O Holding tank: MDC c O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO 'V ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system r 5.Waste Transporter Name of Hauler Destination Waste Product 77 YES NO 1. 2. Pers (s) Inter`viewed Inspector Date t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A O CERTIFICATION Property Address: 77 OLD YARMOUTH RD. HYANNIS MA? 344?AR 053 Name of Owner FRED GOLENSKI �f Address of Owner: 239 BARNSTABLE RD.HYANNIS MA.02601 vEg Q Date of Inspection: 12/28/99 "� N •, Name of Inspector:(:Please Print)JOHN GRACI TO S 2��p I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000) At iNO T F G? Company Name: nla r Mailing Address: n/a �® Telephone Number: n/a L CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate. and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Furtheiubmit ation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:12/28/99 The System Inspector shall a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. V revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 053 Owner: FRED GOLENSKI Date of Inspection:12/28/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla_(approximation not valid). 3) OTHER D& revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 053 Owner: FRED GOLENSKI Date of Inspection:12/28/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will'pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed e y,. revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM(INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 053 Owner: FRED GOLENSKI Date of Inspection:12/28/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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 volumelis less than 1/2 day flow, " X Required pumping more than 4 times in the last year NOT due to clogge� or obstru�pe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure., E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 3"OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No i X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 3"OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-Q g.p.d./bedroom Number of bedrooms(design): n/a Number of bedrooms(actual):n& Total DESIGN flow: nLa Number of current residents:nLa Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): NQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL c , Type of establishment: COMMERCIAL 32'X36' Design flow: n&gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): Na Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:Wa Last date of occupancy: nta OTHER: (Describe) Wa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: DLa System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nLa- gallons_ Reason for pumping: Wa TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1976 Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 3"OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28/99 BUILDING SEWER: (Locate on site plan) Depth below grade: ZE Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: ]I: Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nta Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Z" Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness:4 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Q How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n& revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 063 P Y Owner: FRED GOLENSKI Date of Inspection:12/28/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n/H - Dimensions: n1a Capacity: nta gallons Design flow: n/a gallons/day Alarm present: NQ Alarm level:.ola_ Alarm in working order:Yes_No_: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc. nta DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n(a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) I]L PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) n[a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Ella Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: 1lLa leaching galleries,number: 1lLa leaching trenches,number,length: nta leaching fields,number,dimensions: n(a overflow cesspool,number: n& Alternative system: n/A Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FLINTIONINC PROPERLY THE PIT!.^SAC[h^PTY AT THE TIME OF THE INSPECTION CESSPOOLS: _ (locate on site plan) Number and configuration: Wit Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. Ella Dimensions of cesspool: nLa Materials of construction: n/a Indication of groundwater: Ella inflow(cesspool must be pumped as part of inspection)Ella Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Ella PRIVY: _ (locate on site plan) Materials of construction:Ella Dimensions:n& Depth of solids: Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Q revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 OLD YARMOUTH RD.HYANNIS MAO 344 OAR 063 Owner: FRED GOLENSKI Date of Inspection:12/28/99 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 t BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of Inspec} Map arcel Owner 3�ly ,s� /c�c���s CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST /PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.,. q j�� L/ NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN f RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INT DtXED I THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. cEIY`Y /" AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH X�� 1 5 199 5 THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. id�t0 lEcc THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. s`% ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. ,. THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WASt g D FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE; DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS: PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms No of Current Residents Garbage Grind Laundry Connected to System Seasonal Use I L,'a Cal); NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: � Pumping Records and Source of Information: GALLONS SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: . TYPE!L?�See�pfic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other.(explain) gro�xdlmate age of all components. Date installed,N known. Source of information. ' SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - SYSTEM INFORMATION (Continued) SEPTIC Depth below grade: -Wo mde— Dimensions:r,S . Material of construction: --JeC6ficrete Metal FRP Other} Sludge Depth l/ Distance from top of slud��to bottom of outlet tee or baffle 13 Scum Thickness / Distance from Top of Scujn�9 top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle J ;/ y c. -5 CZ '1006 DISTRIBUTION B X: Comments: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Q r MP CHAMBER: Pumps in Working order? Comments: SOIL ABSORPTION SYSTEM SAS IF NOT PRESENT,EXPLAIN: TYPE: / in - O , Comments:. poe // d !� CESSPOOLS: Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction indication of groundwaW.inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: 7 �7r t�TOWN OF BARNSTABLE / LOCATION ! / � /�/� SEWAGE# � VILLAGE P / ASSESSOA 'R'S MAP&LOT 3� rV'S NAME&PHONE NO. d /V CB SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER fJ/P/ 19 A/ PERMIT DATE: G9?dFq42hN—QE DATE: f� Q Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -----_ i a d,s U� , `,, B� A Q a �� ,� v� O .� �s e `.- � � O 1 �• .. OWN OF BARNSTAB,LAI ,L� LOCATIO , g N ld SEWAGE # VILLAGE W i-3 ASSESSOR' AP& LOT Q Qr -Qr ' I � AME&PHONE NO'. SEPTIC TANK CAPACITY C) 11 / LEACHING FACILITY: (type) `J (size) NO.OF BEDROOMS �t BUILDER O OWNER PERMTT DA COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A Feet Edge of Wetland and Leaching Facility( y wetlands exist within 300 f lea n f_a i 'ty) Feet Furnished by 4 T JO i e r ,` TOWN OF BAR LE : LO CAT ION^' 1 ®kU BAR NS # V> LAGE ASSESSOR'S MAP &LOT `t— INSTALLER'S N PHONE NO. SEPTIC TANK CAPACITY r1 LEACHING FACILITY: (type) (size) /U00 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: /ZZx lcl Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland 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 fe t70f I aching/ ility) Feet Furnished by / t1 ® � � �� --�� � � � Cs-" �- F L 0 CATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i "ADDRESS on � OWNER WNER/� C _ r"Kl'�Ls'r Ne DATE PERMIT ISSUED 6-, Z6— DATE COMPLIANCE ISSUED �� . � : ,��, �1 �, J - �. 4_.y. / ���V FFz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �-; -- ...................................-- . OF.......................................................................................... Appliratinn for Uiipn.ial Works Tonstrurtinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a : 7 -� ................... .........................................._..................................................... �Lo tion-Add As or Lot No. ... ... .....'........................•-^---.... . .... ....... ............. -..-------- ---- er Address W Installer Address QType of Building Size Lot............................Sq. feet U Dwelling YNo. of Bedrooms.... ......................................Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building No. of persons............................ Showers a yP g ------------------•--------- P ( ) — Cafeteria ( ) a' Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic 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.�a._' ©.". ': ........ aTest Pit No. 1................minutes per inch Depth of Test Pit_................. Depth to ground water...................--... Test-Pit No. 2.................minutesper inch Depth of Test Pit.................... Depth to ground water....................---. O Description of Soil...... r._ V ••----------•--••-••---••••-----•-•---•-•...•--••••--•••••----••••---••-•••-••••••-•••--•-••-•-•••.........••••••-•••••••-•...••••-••••••••-•------•••-•••••-•••••••••--.........-•-•-•••••.........••_. W - - --------- • •- �� � V N ure 9f Repairs or Alteratio —Answe when�a licable._ l._.-,�v...®® a�� �`"''�`" .�1. -------------------------------------------••-- •-•-•-•••-•-••-•-•-•-•••-•-•••......•••.._......----•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL ITL% 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 the board f ealth. Signed. . ... !/I.,............................ ............................ Date ApplicationApproved By................................................................................................... ...................... ................ Date Application Disapproved for the following reasons---------------••----•-••------••------------------------------•-------------•----••••-•..-:.................._.. -•------•-•----------•--------------------------------------•----------------•--......----•-•-------•--.............................------...----.....-•--------....-----------•••--••••-•-•-.........--- Date - Permit No....................................................... Issued_- .................................................. Date No....glns7 g. Fmc /1................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH iw ............................OF................ .................................................................... Appliration for Di, poiial r ' ,,,,Towitrnrtiou "antit V Application is hereby made for a Permit- - to Construct or Repair an Individual Sewage Disposal System at* .1 . . - 4 , �/Jf.....................7.7-M-1 ... .. .. . . .....4� ..r ................................................................................................ Z---- --—------ Lo..lion.-.Ad drts or-Lot No. ... ..................................... -- ---- ..................................................... er � ... ..... ....... .... . . ....... ----------------*...........* e Installer .Address U Type of Building Size Lot............................Sq. feet Dwellingj-XNo. of Bedrooms----I......................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) al Other fixtures ----------------------------------------------- --------------------------------------------------- ............. ....... Design Flow............................................gallons per person per day. Total daily flow........*------------------*................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width._.............. Diameter................ Depth................ 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.4.::�2 Ivl.*.i....... Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water.._._.............._.__. Test Pit No. 2................minutes per inch Depth of Test Pit.__.............._.. Depth to ground water........................ .......... ........................ .. ............................................................................................................... ....... 0 Description of Soil. ... ........................................................................ . .................................... U ......................................................................................................................................................................................................... ............ .................................................................................................. --------- .......... .... ...... U Na lure of Repairs or Alterati Ans 1rhenap2hcable.... 1011* W �---- --------------- ...... 1&�........................................................................................................ Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been by th issued b b Signed_.. .....W 44& 0 e oar ' 9d f 14 4.ealth. - ............................ 4 igned- ............................ Date ApplicationApproved By............................................I....................................................... ................I.................... Date Application Disapproved for the following reasons:................................................................................................................- ......................................................................................................................................................................................................... Date Permit No.........................................--------------- Issued.. ................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..........I.......................................................................... Tntifiratr of THIS IS.TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by................4.#�........ ............................. ...................................................................................................... Installer at................................................ ........ ... t o/ ........ ... . ...... ................................................................... E has been installed in accordance with the provisions of TITL 5 of The State Sanitary Code as described in the application for Disposal Works.Construction Permit No.---A V02-------- dated................................................ THE ISSUANC F IS CERTIFICATE SHALL NOT BE CONSTRU GUARANTEE THAT THE SYSTEM WILL F C N SATISFACTORY. DATE.....---- .. ............... ............................................... Inspector ...... ....................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !�Y�. ..........................................0 F..................................................................................... No .... FEE..Z.A.............. Rspoiiat Workii Ton otrudion "prrutit Permission is hereby granted..............00.0%..... ..........................................I................................................... to Construct or Repair an Individual Sewage Disposal .System '��-9.................................................................. ..................... at No.................-X>.........C Street as shown on the application for Disposal Works Construction Permit No..................... Dated............_.............._.............. ......................................................................... Board of Health DATE..............................................4_'�'Lgle _A7........ FORM 1255 A. M. SULKIN, INC., BOSTON PARKING CALCULATIONS: SEPTIC DESIGN FLOW: 197 GPD ALLOWED BY B.O.H. VARIANCE DATED 12/18/85 4 FIRST LEVEL - ONE BEDROOM APARTMENT (110 GPD/BEDROOM) = 110 GPD APARTMENT: 1 DWELLING UNIT = 1.5 SPACES WAREHOUSE.STORAGE FIRST LEVEL USE RETAIL FLOW 1283 SF(50GPD/1000)=64 GPD SECOND LEVEL MEZZANINE COLD STORAGE- NO FLOW = 0 GPD o WAREHOUSE 2100 SF(1/600)=3.5_ SPACES TOTAL: 5.0 SPACES RED. C,P DESIGN FLOW = 174 GPD < 197 GPD O.K. 5 SPACES PROVIDED UTILIZE EXISTING 1000 GAL H-20 SEPTIC TANK, H-20 DBOX AND H-20 6'X6' LEACHPIT NOTE: 512 SF MEZZANINE NOT COUNTED IN ABOVE CALCS. 1000 GAL WITH DESIGN FLOW CAPACITY OF 197 GPD MIN. R THE CHANGE OF USE FROM LEGEND 197 GPD OFFICE FLOW TO MIXED USE OF RESIDENTIAL APT. WAREHOUSE WITH 174 GPD FLOW. 1 � HYDRANT O UTILITY POLE � LOCUS W P — X-'— EXISTING FENCE \ 36 — EXISTING CONTOUR 2 \ J ` \./38.5 EXISTING SPOT mQ /\ GRADE MAP 344 �. rO # 5 9 e EXISTING TREE 4 LOCUS XISTIN MAP SCALE 1 = 2000 G 38 ARKING �90, ASSESSORS MAP 344 PARCEL 33 AREA 4- ZONING: 8 G� NOTE: THIS PLAN IS BASED ON A CERTIFIED PLOT PLAN FRONTAGE - 20 FT / �QP PREPARED BY WILLIAM LIEBERMAN DATED 4/10/86 FOR AREA - 60,000 SF LOT LINE INFORMATION AND DOES NOT REPRESENT AN SETBACKS: FRONT - 20 FT ON-THE-GROUND INSTRUMENT SURVEY BY THIS FIRM. SIDE - 0 FT \/ �O ry� / THIS PLAN IS NOT TO BE USED FOR LOT LINE DETERMINATIONS, REAR - 0 FT /1\37.3 / FENCING, CONVEYANCING OR ANY OTHER USE OTHER THAN O� WP OVERLAY DISTRICT REVIEW FOR COMPLIANCE WITH PARKING AND SEPTIC MAP 344 REGULATIONS. PCL 53 SITE DETAILS WERE TAPE MEASURED FROM EXISTING BUILDING # 7 7 AND ARE APPROXIMATE. TOPOGRAPY AND ADJACENT SITE DETAILS FROM TOWN G.I.S. LIMITED SCOPE / I \ EXISTING METAL DATA AND ARE APPROXIMATE- FOR REFERENCE ONLY. MAP LDING- 344 44 \ S9S. B TIERIOR CHANGES PLANNED SITE PLAN # 65 \ EXISTING SEE FLOOR PLANS OWNER OF RECORD: \ 9� 77 OLD YARMOUTH REALTY LLC PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING •OD, 4850 SF LOT+/- 408 MAIN STREET EXISTING H-20 MAP 344/53 CHANGE OF USE APPROVALHYANNIS, MA 02601 SEPTIC SYSTEM. \- LOCUS DEED REF. DE 16 1 PG 345 LOCATION FROM PLAN REF. PB 1 PG 55 PREPARED FOR: -� INSPECTION ON REPORT 38.5 G� � I: � II CONST. OLOTTI �\ q���F� P o 77 OLD YARMOUTH REALTY, LLC _ \\ ZHOF SS 1� NOFMjSSgc LOCATION : 77 OLD YARMOUTH ROAD, HYANNIS, MA ARNE H. gcyG �o� ARNE y�s� SCALE : 1 " = 20' DATE : 11 -5-03 y H. CIVIL' N OJALA REFERENCE ASSES. MAP 344 PCL 53 k � 4 No. 30792 � �No.26348 Is S% SITE PLAF I \ A L S /H \ ABNtE AA off 508-362-4541 880 SITE OJALA 'Fs \/''�J`�•_ 2OOT fox 508 362-9880 P _ o c N. ; 1 0� 2.. �� \ � CIVIL y � caAL"A ���!� i 20 0 20 40 60 Feet s s4E �' down cape engineering, inc. VIE� Crr_ �,r CIVIL ENGINEERS JOB # 03-194 SCALE: 1 " = 20' S'(ONAI �N6 r, fit- DAT LAND SURVEYORS i; 939 main st. yarmouth, ma . - I I