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Home My WebLink About0011 PIRATES WAY - Health 11 P i rates Way, Hyannis P A 268 191 4 w Vk �� t a Ir i i it I� a + it fl N Ap j .� TO-WN OF BARNSTABLE LOCATION SEWAGE # - J VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. j4 SEPTIC TANK CAPACITY GIMc�cs - LEACHING FACILITYAtype) pl2e—Cl-S% (size) NO. OF BEDROOMS PRIVATE WELL OR�PBLIC EI y BUILDER OR OWNERa ' ISj i! DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��/ r LJ Z>3 '*o ,c-h v� �'-k1 s f/AV TOWN OF BARNSTABLE LOCATION k�M 'l SEWAGE # VILLAGE (11 Via SSESSOR'S MAP & LOT? Q C INSTALLER'S NAME&PHO O. p SEPTIC TANK CAPACITY LEACHING FACILITY: ( ) ��l (size) Ca(A0 NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 70 0 C) 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 �� "� � r _ e n . Tw ' TT 14, goo V Fimic THE COMMONWEALTH OF MASSACHUSETTff .p BOARD OF HEALTH J TOWN OF BARNSTABL 9 -- . Allp iration for Di-gvaaal Works Tonotrnr tnn rrm f Deco z Application is hereby made for a Permit to Construct ( ) or Repair ( (man Individual Sewage Disposal System at: --- ----•---- Location Address or-Lot-No.......... • •-•--- -- T_ :�------------------------ ---------- --.-------.----------- -- ar�ss -- ------- ,Wa S_C � ---... Ow..ner A W ? ............................ --------------------------- ...... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.._....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------•----------------.....--------------------------------.._...------------. W Design Flow.........'.�.....................gallons per person per day. Total daily flow.....--X .O......................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.------_.............sq. ft. Seepage Pit No--------/------------ Diameter.....__ ....... Depth below inlet.... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fX4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ R,' 0 Description of Soil........................................................................................................................................................................ x U --- •------------------- •------------------- ------------------------ •-•-------------- ------------------------------------------------------------- •----------------------------- •----------------- W Nature of Re irs or Alterations—Answer when applicable.- 7._._� r — Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the,provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of health. r Signed ----------------- ...... .......... -------------------------- ...... ApplicationApproved By -------- ------ ---- ---- --------------------------------- ------------------------------------=-------------------------------------- Date Application Disapproved for the-following reasons- ----------------------- - --- -------- ---- --------- ------------------ --------------................---------------- .................... ................... .. ..................... ........... .. .... ................ . ................................................................. Qq Date Permit No. .........:.....1.2..-- 'ram---- ..1 5. Issued -.. .-.2'-.. -�L- ate y A�. . ..,.�, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , TOWN OF BARNSTABLE ApplirFation for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( (man Individual Sewage Disposal System at: ........... •----. ------------------ Lot Lot,........... . Location Address or No. ........................... ,W1 .......... --.......-•----•-----..... . .- -. .... .............. Owne ' J A _ --------------- ........................... ..................... ---.. Installer V Address Type of Building Size Lot.................... .....Sq. feet �-t Dwelling—No. of Bedrooms___--3..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ......................................................... w Design Flow......... _ ..............•._._..gallons per person per day. Total daily flow._.... .....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- ------------ Diameter......-a-...... Depth below inlet.._............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-----------......----------....-------- Test Pit No. I................minutes per inch Depth of Test Pit-_____-_-•-_..____-- Depth to ground water........................ fr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P' -•------•--•-----------------------•--•---•-------------•-------•••-----.....-------------••--------... ----------------- .----------- O Description of Soil.................................................................................................................. ------------•...--------.....__. x c, w U Nature of Rep irs or Alterations—Answer when applicable.__ ?.___ ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued.,by he board-of health. Signed .� . 1- �a_7- ------- Date --.......... ;Application Approved B Date Application Disapproved for the following reasons: ................... .................................... .------------.. --------------------..........-------- -------- q 2 L Date Permit No. 2 -�-� ...1 Issued --- - ............................... ------ bate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C rdift.cate of C�omyitance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( t ) or Repaired ( �---) by....................................... --(1 .-C 1. `L.f-L------.....--------------------------------------------------------------------------------------------: Installer at7-- ------------ ---------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as es gibed in the application for Disposal Works Construction Permit No. .5-4---- - ......... dated -----�....2-,..... /9:..-....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE-THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- --------f.. — � Inspector ' . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE � mac, + FEE.... ..� .... Disposal Marks Tonotrudion Vrrmit Permission is hereby granted........... ... to Construct ( ) or Repair )—an--Individual Sewage Disposal System atNo...............•---•-----------------`�....... �r_�`C�=S... --��`---------------f.- c�9 yr. Street /� as shown on the application for Disposal Works Construction Permit Nog Z_..... Dated...... 1-- /S. -.---.... �� 2- .. ... Board of Health DATE...............--••--2........ .---------------------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS COMMONWEALTH OF MASSACHUSETTS rA EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRON=NTAL PROTECTION RECEIVED, David B.Mason,RS,Certillied Title V Inspector,508-833-21 7 JUL 0 2 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION , Property Address: it Pirates Way,MA ASSESSORS MO ' NO,• 8 Owner's Name:Jobe Kennedy `�`' fC. N0: . Owner's Address: Same Date of Inspection:May 27,2004 Name of Inspector:(please print)David B.Mason Company Name: N.A. Mailing Address:4 Glacier Path East Sandwich,MA 02537 Telephone Number.508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was pery°stems.i am a DEP rmed> onmy training and experience in the proper fimction and maintenance of on site sewage disposal sy approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000� The system: X Passes _Conditionally Passes Needs Further Evaluation by the Local Approving Authori Fails Inspector's Sigma Date: - - O, 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. Notes and comments:System as inspected appears to have operated based on occupancy level. Cesspool acting as septic tank should be pumped as a matter of maintenance. Increase in occupancy may casue hydraulic failure.The information as identified represents only the condition of the system on May 27,2004 at 2:00 PM. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. f Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ inX_ I have not found any information which indicates that any ofthe failure criteria described in 310 CMR 15.303 or 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or 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: 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 COMPLETED) distribution box is leveled or replaced (THIS IS REQUIRED TO BE 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS i f Page 3 of 11 PART A CERTIFICATION(continued) Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 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 **This system passes ifthe 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I Page 4 of 11 CERTIFICATION(continued) Property Address: 11 Pirates way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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 NA Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow T _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. XX 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 acoeptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner 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 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 H 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 sigmfic ant 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 Check if the following have been done.You must indicate des"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?(INCLUDING THE SAS) X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of constriction,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 CNM 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: li Pirates way,West Hyannis,MA Owner: John Kennedy Date of Inspection:May 27,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3_ Number of bedrooms(actual): 3 DESIGN flow based on 310 CM 15.203(for example: 110 gpd x#of bedrooms): 330gpd Number of current residents: Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2003;91,500cu.ft. 2002;80,700cu.ft. Sump pump(yes or no):No Last date of occupancy: (current) COMMERCIALRNDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/personslsgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Property owner Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:_ Gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _InnovativetAlternative 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 X Other(describe): Initial cesspool acting as tank with tees. There is an overflow cesspool and another onverflow precast leaching pit. Approximate age of all components,date installed(if known)and source of information:Original apprax. 1968 with the precast pit about 14 years ago. Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Pirates Way,West Hyannis,MA ` Owner:John Kennedy Date of Inspection:May 27,2004 BUILDING SEWER(locate on site plan) Depth below grade:Approximate; 18 Inches Materials of construction: cost iron _X 40 PVC other(explain): Distance from private water supply well or suction line: NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage.Sewer line is orangeberg. SEPTIC TANK:N.A.(locate on site plan) Depth below grade: 12" Material of construction: _concrete metal_fiberglass_polyethylene_X_other(explain)_Cesspool Block If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 6'X 6'Block Cesspool Sludge depth:5 inches Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle: 16" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:actual 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.)Requires maintenance pumping. Outlet tee in good condition. Appears to be slight plumbing leak due to continual flow. GREASE TRAP: N.A. Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM—NOT F0111 Vnl.rnvTeuv s.reFceturrrrc Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 TIGHT or HOLDING TANK: N.A._(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: aallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even with outlet pipes. One outlet pipe had a flow leveler. Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Page 9 of 11 Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 6'X6' _leaching chambers,number:(3)Cultecs —leaching galleries,number: — leaching trenches,number,length: _leaching fields,number,dimensions_ X 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, etcj.No indication of staining,no ponding or damp soil. Overflow cesspool was empty and the leach pit was empty. CESSPOOLS: NA_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(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.): f - Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Pirates Way,West Hyannis,Ma Owner:John Kennedy Date of Inspection:May 27,2004 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. oWl � I I I I � � L(01 , V , �L 2 [ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 11 Pirates Way,West Hyannis,MA Owner:John Kennedy Date of Inspection:May 27,2004 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water 20 feet Please indicate(check)all methods used to determine the high ground water elevation: _X Obtained from system design plans on record-If checked,date of design plan reviewed: X Observed site(abutting prW"/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain:Recent Test Holes. Existing engineer records with BOH X Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. I barnstable Assessing Search Results Page 1 of 2 t P y t, ai��Csr�lE�—/Grr AL- CO ° L fyn ibA�%� Home: Departments: Assessors Division: Property Assessment Search Results 71 11 P1RAT'vES WAY Owner: Property Sketch Legend KENNEDY,JOHN B& Map/ParceUPancel Extension 268 /191/ Mailing Address KENNEDY,JOHN B& 6 KENNEDY, LYNN 33 PLEASANT ST WAYLAND,MA.01778 , eLLp 2004 Assessed Values: ` Appraised Value Assessed Value Building Value: $88,200 $88,200 Extra Features: $5,000 $5,000 Outbuildings: $0 $0 Land Value: $113,700 $113,700 Interactive Property Map: -N-h-preciuires Plug in: Totals:$206,900 $206,900 1 have visited the maps before I � ,I Show Me The Man April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: GILLESPIE,JANET B 10/25/1996 10452/087 $ 1 GARRY, BARBARA MARIE& 12/15/1987 6073/125 $1 GILLESPIE,CHARLES&JANET 12/15/1987 6073/117 $ 1 GARRY, BARBARA MARIE 2/15/1985 4383/230 $1 WESTBROOK,JANET B 2650/344 $0 KENNEDY,JOHN B& 4/14/2000 12948/094 $ 147,000 http://www.towrLbarnstable.ma.us/to.../&playparce103.asp?mappar=268191&SearchBy=Addres 6/1/04 r Barnstable Assessing Search Results Page 2 of 2 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $1,367.61 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax Hyannis FD Tax $420.01 C.O.M.M, 1.10 Cotuit 1.52 Land Bank Tax $41.03 Hyannis 2.03 West Barnstable 1.36 Total: $1,828.65 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0.32 Year Built 1968 Appraised Value$113,700 Living Area 1320 Assessed Value $ 113,700 Replacement Cost$106,302 Depreciation 17 Building Value 88,200 Construction Details Style Ranch Interior Floors CarpetHardwood Model Residential Interior Walls Drywall Grade Average Minus Heat Fuel Gas Stories 1 Story Heat Type Hot Air Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms 3 Bedrooms Roof Cover Asph/F Gls/Cmp Bathrooms 2 Bathrooms Total Rooms 6 Rooms Extra Building Features Code Description Units/SO ft Appraised Value Assessed Value FPL1 Fireplace 2 $5,000 $5,000 Property Sketch Legend BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTO Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/to.../displayparce103.asp?mappar=268191&SearchBy=Addres 6/1/04 COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f I CERTIFICATION Property Address: PIRATES WAY WEST HYANNISPORT, MA 026 2 pZ�g-' Name of Owner JANET GILLESTIE Address of Owner: 22 PIRATES WAY HYANNIS MA.02601 Date of Inspection: 3/6100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: TITLE V SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET MA.02536 Telephone Number: 608-564-6813 CFRTIFIGATION 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 _ Conditionally.Passes _ Needs Further Evaluatio By the Local Approving Authority Fails Inspector's Signature: t Date :WO The System Inspector shall suiLlt 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 Inspection Is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6/00 INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: X I 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. 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. 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. n& 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 n& 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6100 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 16.303(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 n/a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6100 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 volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. - 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 compounds, ammonia nitrogen and nitrate nitrogen. 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 witha 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 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner: JANET GILLESTIE Date of Inspection: 316100 Check if the following have been done:You must Indicate either"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 - 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 - I)dsting 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 9/2/98 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6/00 FLOW CONDITIONS RESILIFNTIAL: pp Design(low: - g.pd7bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: !!;c gpd ?j7jC� Number of current residents:1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings.If available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM M ERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of Information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of Information: ORIGINAL 1968 WITH A NEW PIT APPROX.10 YEARS AGO Sewage odors detected when arriving at the site:(yes or no), NO I revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 316/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THE SEWER LINE IS ORANGEBURG.THERE IS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 6'X 6'BLOCK CESSPOOL" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" 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: n/a 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.) MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL 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: (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.) nla revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 316100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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: NO Alarm level:n/a Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a 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.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6100 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: n/a Type: leaching pits,number:(n/a)1000 GAL 6 X Ei 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,dimensions: (n/a)n/a overflow cesspool,number: (n/a)6'X 6'BLOCK CESSPOOL Alternative system: n/a 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 PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.THE BLOCK OVERFLOW HAD 3'OF WATER IN IT,AND THE NEWER LEACH PIT HAS NOT HAD MORE THAN 6"OF WATER IN IT. CESSPOOLS: _ (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: n/a inflow(cesspool must be pumped as part of inspection)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 revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 318100 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) ��cic g Q a o A� ati qj Ac- 3°6 gc a° revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 PIRATES WAY WEST HYANNISPORT, MA 02672 Name of Owner JANET GILLESTIE Date of Inspection: 3/6100 NRCS Report name: nla Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep— SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 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 Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER IS AT 10+FEET FROM MAPS AND CHARTS revised 9/2/98 Page 11 of 11