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HomeMy WebLinkAbout0038 PAWNEE COURT - Health 38 PAWNEE COURT, HYANNIS A:289 — 005 i I i o a I� i i `'� `-� L � �� � � � � ._ 'i � � A I � O `T'(`_ II I � S � � �� 1 � � ) .� � � � � i \� - v �{{ it �\ � V I� S- ``\,,� ^J � �, N v � � � � � �� � �, t � �-- if � �, ���� �- �� �, '.� L ram*`' i a.., ,� <»Y { �: a r ,� �'-�,< g' y x�.� :. j x € w ., s� �. s + r .w.. +}" 1-. i, ,g -r r .. 'r`< 1 t x— -a �'14'^ � �i+� '' N' j V- y� _a! �'�'h':a#' d 5 w ;i5e t x +'�'� �'fi, $ ,rT'[�" q7c �y, "�,{. �t 's y .�._✓ a: 3' a '� w`akzr as+". •, a."sr ca^3 Pw C ",, 4- x i T` V T' sl,� ..'4,# t Y t i 'any a� 3 54 .gw3,, �k `4 f 'a*3+ *A �3 d `� ,1 M� z A, �*q# a5s,: -` 5r n �j, ��' c€ r ,t axfms,. xti:t<`r'`y 3�'�'�,:M;rz� v a w -n� r.; ,+r. ` ` - s + e r ut t{f5.€ h ad'h H 1 Y' f 1°� �, g �, 4 sE •'; '& iW �`, n �� 'S t � ' ` 3?+?`t '�a,:,$�ac� �*�a a �'a+"'`��a ``'� 9 � t a _kx��n �r i'`� .d' is a'`K x� 5. f `; v r x� C `n ifa. %r4" s 5 4 t ,i +�e -, °, nz r S a .��yy ;i w &"I t #. x � _ 5! "'-. • t ram' !�!Sr k Vd m ,'.t is "`� x t" ,yt, a ',F, I i - J .j¢ S , "M1 ::i i Y. +SS `� kv h, .1 �i 4 ,� �' ; f;- f +� S v IN 5 � .. A 4 f�i�w Yt t� y s ° �' t ,,P 7yt ham. { ¢.` +� k t a r - x` x : Y a z *, } t 4 , ''S, PgS F ¢+ k � 4 5 Y '" t � �� "� ^-- y, F 'S�4:�b V .,t5� y'k c e. 3 t y >F-f, ��x „ u"$ '�fi € r «F �, '. �} -- t - . s�*' a' �' a , + p ..�' .r. -. h j ` y� � h` tip- ?t &° b f § ,' . ..:4 — d r Z y.• r f - lb s E ;` } .. .. y t $< 4 �3 -�1M + 3 t ,i P T `l. a _ u - �f x r _ + al , d Y A 9 \ '� „ 2 d x'. f � 4 ;,� xv; d '� a a -s t .. x ,..- R - ,'zr - , ., .. -1 r F r ,� r ll. _ ,- , _ - 3 — A^ n�.. ,. .- .. a b C- : d �� r .-- WM. -:,- .,' .- ' : ya ;} n.:, Y L. :t .i �.. - n ,. ,. _ TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE S ASSESSOR'S MAP & LOT v799"' DOS INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /�r�✓ LEACHING FACILITY: (type) 022 (size) NO.OF BEDROOMS -2- BUILDER OR OWNER C c r PERMTTDATE: 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 i \Wl r't ^ C w � o w � 1 �°o 0 vA � y i { TOWN OF; ARNSTABLE f 'LOCATION. 3 ��� a e C7f SEWAGE # r: VILLAGE �4 �, S ASSESSOR'S MAP & LOT ��`/—.005�` INSTALLER'S NAME& PHONE NO. I j SEPTIC TANK CAPACITY -17 I EAGHING FACILITY: (type) 02- 5 O CLr{�•-��r9 (size) X a "D X � NO. OF BEDROOMS .Z BUILDER OR OWNER PERMIT DATE: �� COMPLIANCE DATE: i Separation Distarice-Between the: Maximum Adjusted Groundwater Table to the Bottom ofLeachina 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 I Furnished by ! 1 � 41 .� 13 , ,:23-�i7- 3(7 a Dos Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the.end of the form. Important:When filling out forms A. Inspector Information SI41531(,P on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M_Jones Title V Septic Inspection _ use the return Company Name key. 74 Company A Lane Co Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522. sean@smjonestitle5.com License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section M340 of Title 5 (310 CMR 15.000); I have personalty inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/15/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and"copies sent to the buyer, if applicable, and the approving authority. Please note: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. MrAp.do•rev.7262018 Tdle s official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis annis Ma 02601 4/16/2021 page. City/Town state Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The property located at 38 Pawnee Ct Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 leaching chambers.Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank-will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): .Pa 2of18 t5insp.doc rev.7@8/2018 Title 5 Official inspection Fenn:Subsurface Sewage Disposal System ge Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt) - 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled;or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y • ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: tSirmp.doc•rev.M26f2018 Tfle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information Is required for every Hyannis Ma 02601 4/15/2021 page City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5lnsp.doc•rev.7262018 Tale 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for,Voluntary Assessments 38 Pawnee Court `J Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspoolis less than 6"below invert or available volume is less than%day flow El ® 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 groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El N Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El N 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 2000 gpd- s 10,000 gpd. ❑ ® 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.- 5) 5) 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 CA. 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 t5insp.doc•rev.712612018 - Title 5 official Inspection forth:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. You must indicate"yes"or"no"for each of the following for all inspections: � 6. y 9 P Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health r El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.MUM 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. City/rown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: .110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: 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: current Datt5insp.doc•rev.7/26=8 Tide 5 official Inspection Fort:subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.MAM18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Pape 8 of 18 I t\ Commonwealth of Massachusetts Title 5 Official Inspection 'Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v' 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page- Cityrrown ' State Zip Code Date of Inspection D. System Information (cunt.) 4. , Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system.by system operator under contract ❑' Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: system installed 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet - Material of construction: r ❑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.): Joints in good condition, no leakage,vented through roof. t5insp.doc-rev.MIS2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System.Page 9 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate or.site plan): Depth below grade: 1 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: 1600 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2'r Distance from top of scum to top of outlet tee or baffle T Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet,tank was not leaking and was structurally sound. t5insp.doc-rev.7r2612018 TAB 5 Official inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owners Name r information is yannis Ma 02601 4/15/2021 required for every H page. City/Town State Zip Code. Date of Inspection. D. System Information (cunt.) 7. 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.): 7 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5msp.doc•rev.726/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis annis Ma 02601 4/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Distribution box was video inspected and found in good condition with no rot. Water level was even with outlet invert_ t5insp.doc•rev.7/M018 rMe 5 Ofrxial kapection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 38 Pawnee Court _ Property Address Oneil Owner Owner's Name information is required for every Hyannis Ma 02601 4/15/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: . ❑ leaching pits number: ® leaching chambers number2 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doe•rev.7/2S/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 13 or 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil _ Owner Owner's Name information is Hyannis Ma 02601 4/16/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): leaching facility was dry with no signs of past overoading 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/282fN8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 38 Pawnee Court Property Address Oneil Owner Owner's Name information is required for every Hyannis, Ma 02601 4/15/2021 page. Citylrown State Zip Code. Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7a612o18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 0118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is H required for every Hyannis Ma 02601 4/15/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 14. 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 i L1 L) ❑ io `� ti �r � Z2 t5msp.doc•rev.7/26/2018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court Property Address Oneil Owner Owner's Name information is Hyannis Ma 02601 4/15/2021 required for every y page. Cityfrown State Zip Code Date of Inspection, D. System Information (cont.) 15. Site Exam: ❑ Check Slope El Surface water - ❑ Check cellar Shallow wells Estimated depth.to high ground water. 1 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 groundwater elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5inmp.doc-rev.7/26f2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Court `J Property Address Oneil Owner Owner's Name information is Hyannis Ma 02601 4/15/2021 required for every y -- page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5lnsp.doc•rev.7rM2018 Title 5 Official Inspection Form:SLbawface Sewage Disposal System-Page 18 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 38 Pawnee Ct � Property Address Donald Crocker Owner Owner's Name ti77 information is required for every Hyannis Ma 02601 11/26/2016 page. City/Town State Zip Code Date of Inspection ►-� r..e Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, / use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyrrown State Zip Code 774-248-4850 smjonestitle5@gm6il.com S14522 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the cal Approving Authority 11/26/2016 Inspector's Signature Date The system..inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health orb i EP)within 30 days of completing this inspection. If the system is a shared system or has a design ow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 38 Pawnee Ct Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and a 2 500 gallon precast leaching chambers. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments w„ a 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02661 11/26/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any'question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example; a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct. Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number f 0 o current residents: 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: unknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct M Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract f ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments se`'y 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 2001 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1.5 Depth below grade: 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.): Joint were ok, no leaks, vented through the roof " Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 gallons 5-1 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.. Scum thickness 3,. 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 10" How were dimensions determined? opened covers, tookmeasurements 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 should be cleaned soon and again every 2 years.Water level was good, tank was structuarlly sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of.last pumping: Date t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes. ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any, evidence of leakage into or out of box, etc.): Distribution box was found to be in good condition, no rot, water level was even with outlet invert. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: 2 ❑ leaching galleries number: El 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 chambers were found to be dry with no stain line observed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owners Name information is required for every Hyannis Ma 02601 11/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 no 1 A -1 , AZ D3 13-7 r, A-3 13-3 Sys t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. Citylrown 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Pawnee Ct Property Address Donald Crocker Owner Owner's Name information is required for every Hyannis Ma 02601 11/26/2016 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. t � Fee Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Disposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair C" rUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot War V6,w(\ee— (:A Owner's Name,Address,and Tel.N . �Axc � I\N%a V o ,�_rD CC,00V--Cf Assessor's Map/Parcel Insta�j u ller'sng,Address, Te ra. �l.No. (� �� Designer's Name,Address,and Tel.No. W-d !'" �G. Type of Building: 9'6 V6 a 9'\{ 06 6q Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank e)<(SAC l 15-0 o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (Y►6i�� SZ O G. t A I ` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this BoaM_ofQVIth. I Signed Date Application Approved by Date �— Application Disapproved by Date for the following reasons Permit No. Date Issued �-* �— i , No. C5'0 ✓ t Fee / �Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS Yes 01ppiication for ]Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(\/�'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. W V&W neC C_-� Owner's Name,Address,and Tel.N . 1r act G.c o o��f Assessor's Map/Parcel Insttaller's ame,Addre�gnil Tel.No. �� Designer's Name,Address,and Tel.No. (� Type of Building: 9"616 a.9\f 06(oq Dwelling No.of Bedrooms •- -Lot Size sq:ft Garbage Grinder( ) Ii Other Type of Building No.of Persons Showers( )'Cafeteria Other Fixtures Design Flow(min.required) ``' gpd Design flow provided gpd } Plan Date Number of sheets Revision Date Title j Size of Septic Tank e;K(Sk l l`(4 (5_0 0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Cyr,`t 0 A 1c Q+( 'TAAk, a Date last inspected: 9 i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i `P accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of alth. /I-- Signed Date I I l9 Application Approved by Date i K: Application Disapproved by Date for the following reasons Y ' Permit No. �C ) ^ -/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE,MASSACHUSETTS M Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired 0/ 1) Upgraded( ) Abandoned( )by { at_ "�u �G�S I�.��i ( .� �t�/ MtS has been constructed in accordance J withthe provisions of Title 5 and the for Disposal System Construction Permit N40 16 dated / �— t Installer �A Designer #bedrooms Approved design flo , gpd The issuance of thi permit hall not be construed as a guarantee that the system w;f�ne.�iol, J as designed. Date �. / J Inspector ' + k/' ---------------------- --- --- ---- ----------------------------------------------------------------------------- ----------------- ys /so No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS ]Disposal 6pste Construction Vermit Permission is hereby granted to Construct( ) Repair ) Upgrade( ) Abandon( ) System located at 3 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 mupt be co pleted within three years of the date of this perm Date `�}- Approed by r RUG 29 2001 8: 50RM ROUGERU, BUTLER & LRRGRY 508-778-6866 p. 2 Blc., 24�.78 P�3�8 #63046 .. . . ..::.. a 08:•„28-2001 12 a 39a DEED RESTRICTION WHEREAS, DONALD CROCKER of Hyannis, Massachusetts is the owner of property located at 38 Pawnee Court,Hyannis, Massachusetts;being shown as LOT 5 on a plan of land duly recorded in Barnstable County Registry of Deeds in Plan Book 183, Page 21;and, WHEREAS,DONALD CROCKER as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a variance . from the 310 CMR 15.214 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and to obtaining a building permit for this lot; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting the variance from 310 CMR 15.214, State En-vironmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing the issuance of a building permit for the construction of a single family home on this lot is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW THEREFORE, DONALD CROCKER, does hereby place the following restriction on his above-referenced land in accordance with this agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. DONALD CROCKER may have constructed upon the lot a house containing no more than two(2)bedrooms. DONALD CROCKER agrees that this shall be a permanent deed restriction ' affecting 38 Pawnee Court, Hyannis, Massachusetts, and being shown as LOT 5 on the plan recorded in Plan Book 183,Page 21. For title of DONALD CROCKER, see the following deed: Book 13370, Page 220. AUG 29 2001 8: 50RM ROUGERU, BUTLER a LRRGRY 508-778-6886 p. 3 a L \ Executed as a sealed instrument this 0- day of August,2001. i,.s Izf Donald Creekir COMMONWEALTH OF MASSACHUSETTS Barnstable,ss. August:i ,2001 Then personally appeared the above named Donald Crocker, and acknowledged the foregoing instrument.to be his free act and deed,before me, Richard P:Largay Notary Public L My Commission Expires: 5131/07 -THE E TOWN OF BARNSTABLE Bp raw OFFICE OF a B sTasz, BOARD. OF HEALTH WAS& -ems 039. `em 367 MAIN STREET 'ED MAY k' HYANNIS, MASS.02601 January 29, 1999 Robert Sydney 106 Athelstane Road Newton Centre, MA 02459 RE: 38 Pawnee Court, Hyannis Dear Mr. Sydney: You are granted a variance from the Board of Health Interim"330 Regulation",to construct an onsite sewage disposal system at 38 Pawnee Court, Hyannis, Massachusetts. This variance is granted with the following conditions: (1) No more than two (2) bedrooms are authorized. Dens, study rooms, finished attic, sleeping lofts, and similar-type rooms are considered"bedrooms" according to the Massachusetts Department of Environmental Protection. (2) The applicant shall record a deed restriction at the Barnstable County Registry of Deeds with respect to the two bedroom maximum restriction. (3) The dwelling shall be connected to the public water supply. (4) The dwelling shall be connected to town sewer line when/if it becomes available. a;t DESIGNING ENGINEER MUST INSTALLATION AND CERTIFY SUPERVISEWRITING THE SYSTEM WAS INSTALLED IN STRICT 4CCORDANCE TO PLAN. sydney (�C./ This variance is granted because the applicant testified that the dwelling will contain only two bedrooms. It is the opinion of the Board that the construction and use of an onsite sewage disposal system for a two bedroom single family house should not significantly alter the groundwater quality in the area. cerely ours; A, Y' Ac in Chairm Boar of Health Town of Barnstable RAM/bcs sydney / 1 BAY STATE PIPING COMPANY, INC. PIPELINE CONSTRUCTION 174 AIRPORT.ROAD HYANNIS,MASSACHUSETTS 02601 (508) 775-9268 FAX (508) 775-9329 June 8,2001 Don Crocker P.O. Box 214 Hyaratisport,MA 02647 Re: Proposed Pawnee Court.8'.'Main Extension and Services; Dear Don We are pleased to quote our Lump-Sum Price of Seven Thousand Five Hundred Dollars ($7,500:00)to furnish the labor,equipment, and materials to install the proposed 8"water main extension and services on Pawnee Court in Hyannis, MA in accordance with the"Pawnee Road Project"'specifications outlined in Exhibit A. Any change in design by the Barnstable Fire Department or Water Department would require a price revision. Exclusions: • . Trench Restoration • Loam and Seed • Permits or Fees • Asphalt Patching Thank you for the opportunity to quote on this project. Should you have any questions, please feel free to contact me.at your convenience. Payment Terms: Credit Approval required before starting. $1,875.00 Down Payment before mobilization. Balance Due Net 30 Days after invoice date. Sincerely, „ ames A. Clark Estimator r' /ivs��r�'.7/ �y g�%,S'I'�7� �/�!✓ APPROVED BY: TITLE: SIGNATURE: i, �,' DATE: u . N TOWN OF BARNSTABLE i LOCATION � PAU �Q � C� SEWAGE# do! (9 -,4L4Js VILLAGE ASSESSOR'S MAP&PARCEL ;t CY9 0O S INSTALLER'S AME&PHONE NO. C.Q �rC w �'"(�� 1 ON, ` SEPTIC TANK CAPACITY Mu"' T S-_C S-D U &AL <- � f LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: ;z (,- 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 Ok .�, � � � � t� i1i` Il � � i ) � � � � � }� � � � Gtir�,S� 3 G -b LJ -� � S S ��i r� (� J � �� �� / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Ys PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ts. 0(ppYication for �izpaaf *pztem Construction Permitpr Application for a Permit to Construct('pair( )Upgrade( )Abandon( )�❑Complete System ❑Individual Components Location Address or Lot No. j 1�� Owner's Name,Address and Tel.No. 4Y Assessor s Map/Pazce �®ge s Installer's Name,Address,an Tel.No. Designer's Name,Address and Tel.No. VAfilp_­5 10-Vo2 W Z�'Z.�PI�j�ct}y� Type of Building: Dwelling No.of Bedrooms 2- Lot Size 0035 sq.ft. Garbage Grinder W6 Other Type of Building No.of Persons Showers a Cafeteria) Other Fixtures Design Flow 2'"L d gallons per day. Calculated daily flow gallons. Plan Date /'Z—"3y^���Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. ,d� -/�/� Description of Soil O11- 3 41 D /GS .3 A r- /ZO.ro , /0 l2 C, Nature of Repairs or Alterations(Answer when applicable) DESIGNING ENGINEER MUST 111:01ALLAj:0N AND CERTIFY IN WRITI Date last inspected: THS SYSTEM WAS INSTALLED IN 4 '�I akLL D 114 COMPLIANCE ACCORDANCE To PtAW. �?rf."'H TITLE 5 Agreement: �a � The undersigned agrees to ensure the construction and maintenance of the More'descnbed,on e�ag�:dis-site'� system in accordance with the provisions of Title 5 of the Environmental Code and not to plat h i§ie tit peraiQ until a Certifi- cate of Compliance has been ' edwo oaz�bof th Signe Date Application Approved by22WI Date Application Disapproved for the following reas Permit No. Date Issued No. � e./c-/ �\ f Fee 60 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for ]Diopool 6p5tem Cow5truction Permit Application for a Permit to Construct(VRepair( )Upgrade( )Abandon( ) ❑Complete System" ❑Individual Components t Location�Address or Lot No.—.�$ r-z� Owner's Name,Address-and Tel..-..No. Assessor's Map/Parcel �Q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.:7 `5, 2 J rL(o �li�lOc�fta-r�-p. Type of Building: Dwelling No.of Bedrooms 2 Lot Size/0�3S sq.ft. Garbage Grinder©) Other Type of Building No. of Persons Showers) CafeteriA(, ) Other Fixtures Design Flow Z-'Z-C> gallons per day. Calculated daily flow 3Z 1 gallons. Plan Date /2-30—` i Number of sheets / Revision Date !f— Title Size of Septic Tank Z6, "L - Type of S.A.S. Description of Soil O �' 3 v 09,2 iGS 3 ' /,Ni /n 4 /Zo o— 7/3 AIM &Z L— Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system .; in accordance with the provisions of Title 5 of the Environmental Code and"not to place the system in operation until a Certifi- ' cate of Compliance has been ' ue y h' oacd,o fHe lth. Signe Date Application Approved by l Date Application Disapproved for the following reas 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 �5e•, � � C c �` `� �l has e n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Mtgool *pgtem Cow5truction Permit„ Permission is hereby granted to Construct(/ )Repair( )Upgrade( )Abandon( ) System located at e r .,v�A_ C,1 K c VV _i n a,id as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to =0ved: with Title 5 and the following local provisions or special conditions. Construction must b - -rmlite completed within three years of-the date of tiu�},... _o. Approved b Date: pP yam `_ ,r Tf�V✓N O1~' ARtSTAB.LE LOCATION 3� wyl 2 Cf' , 3 c �_ SEWAGE J R; VII-LA E'. O© ti 'AS R'S:ESSO S MAPS& LOT G3. - INSTALLER'S NAME:Bz PHONE NO. - J. SEPTIC TANK CAPACITY LEACHIIV.G.FACILITY: (type) __02- SO;0 o CCi«,��r > _ (size NO. OF BEDROOMS' .2: : s BUlhDER OR OWNER C PERMITDATE: oo COMPLIANCE DATE: Separation DistanmBetween.the Maximum Adjusted GroundwataTable.to the Bottom of Leaching Facility Feet Private Water Su 1" Well and Leachin Facili PP Y $ ty (If'any.Wells exist. on site:.or:within 200 feet of leaching facility.) Feet Edge of.Wedand and Leaching Facility (If any wetlands exist within 300 feet of leaching'facility) Feet l ...Furnished by -- . --- 7. rti ��4. : l (' f r' SULLIVAN ENGINEERING INC. 7 PARKER ROAD/P O BOX 659 OSTERWLLE, MA 02655 Peter Sullivan P.E. Mass Registration No. 29733 psullpe@aol.com phone 508-42873344 RECEIVED fax 508-428-3115 October 3, 2001 r OCT.A5 2001 Board of Health TOWN OF BARNSTABLE Town of Barnstable HEALTH DEPT. 367 Main Street Hyannis; MA 02601 RE: Pawnee Court, Hyannis Map 289 Parcel 005 Dear Board of Health, - Per your request, I inspected the septic system at the above referenced property on September. 26, 2001. I inspected the system prior to back filling and found it'to have been installed in substantial compliance with the Plan of Record. The leach field itself was measured slightly larger (14' x 25')than the original design requirement of (12'. x 24'). At the time of inspection, town water had not yet been installed. I trust.this meets your present needs. If you have any questions, please feel free to contact my office. Very truly yours, Peter Sullivan PE Sullivan Engineering Inc. Cc: Don Crocker P0 Box 214 Hyannisport, MA 02647 Members of American Society of Civil Engineers, Boston Society of Civil Engineers Z6 ' dF DATE t ? URNB ASM FEE: Town of Barnstable REC. BY—/%, Board of Health 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kauflnan,M.S.P.H. Ralph A.Murphy,M.D. VA iAN l FQt1FST FORM LOCATION Property Address Zw,,.e; C,©y,r—� v Z h••� ; $ Assessor's Map and Parcel Number. aj Ct— 0 O 1 ,Size of Lot: (©,O Wetlands Within 300 Ft. Yes Subdivision Name: e.l., No Business Name: h on2 APPLICANT CONTACT PERSON Name: M•kes Name: 'Ro6Qr-Ar l oto }4,e1 I.*z•.a R o Address:�7 Address: �1 �1— .gM A a3 V�;-Cv F'2r✓•�v -1 -`F/ S l�.T T. - oyC9 too Phone: ��+tot1 7�S ais�Z3 ' Phone: FAX: n2 FAX: �(ot?) J-17 Q03O VARIANCE FROM REGULATION(ust R g.) REASON FOR VARIANCE(May attach if more space needed) `c> c��►s`�r..`-E Z `�wa -• �2�(/oo�r. �16>tn�2 u i CDA A 0104S�WL« :CAolzt SvS`�'L SQ C.�i s7✓1 hecklist(to be completed by office staff-person receiving variance request application) Foui�(4)copies of'plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no fee for liregmud modification reneml2.grease trap variance renewals(same ownerActs"only(,omuide dining variance renewals(rune ownealewee onlyL and variances to repair failed wrage disposal systems(only if no expansion to the building popmedn Variance request submitted at least IS days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A. Murphy,M.D. Q:/WP/VARIREQ I _ I f 106 Athelstane Road Newton Center, MA 02459 January.8, 1999 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 ' Re: Variance Application To Whom It May Concern: I am writing on behalf of my father, Miles.Sydney. Please find enclosed variance applications for two lots of land located in Hyannis Massachusetts. My father requests that these applications be considered^at the meeting of the Board of Health on January 26, 1999. Also enclosed are checks for the filing fee for each application. The four copies of plans required for each application shall be filed in your office on Monday, January 11, by the civil engineer or his agent. I understand that it is my.responsibility to notify abutters to the properties of the hearing at least ten days prior to the hearing date. If you have any questions, please feel free to,call me at(617) 727-4732 ext. 133. Thank you for your attention to this matter. 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