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HomeMy WebLinkAbout0042 PITCHER'S WAY - Health 42 Pitcher's Way Hyannis P A 289 064 u w ii � o L IL f A i e ilYIYrr u p ,ry,Ullil- • Er fU rl Postage $ u1 Certified Fee ` ostmark �7 O Return Receipt Fee C Here ru p (Endorsement Required) s M Restricted Delivery Fee M (Endorsement Required) M Total;Postage&Fees m ,Y Sent ToIb � Street,Apt lVo� - - = =- o. r --PO Box N------ . .........--•---.10.. y� � �..,/-, city S , f r fl l rl lA �l�ll/ ------- :rr rr. Certified Mail Provides: o A mailing receipt tr A unique identifier for your maiiplece a A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mails or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. k o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present'it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 UNITED STATE f7Md..1StKRlb .'-E R1.I • Sender: Please print your name, address, and ZIe4 ir8his box • -n �- n 10 s-b a dip 1-hi tp_- D M a 11i D2(o,01 SENDER: ■ Complete items 1,2,and 3.Also complete A. Sign re item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X Addressee so that we can return the card to you. B�teceived by W'qted C. ate f ell e ■ Attach this card to the back of the mailpiece, 1 �j„v t� or on the front if space permits. i1 Iva 1. Article Addressed to: D. Is delivery address different from item 1? es If YES,enter delivery address below: No IV 'I �n MAE1 OyW �j 3. Service Type Certified Mail ❑Express Mail � ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. tt 4. Restricted Delivery?(Extra Fee) p Yes 2. Article Number : f ;!! t t r ' y !'' ;' i i S i . (Transfer from service labeQ 8 3 2'3 0 0 D 2 5"17`'8 2 9 4 7 J PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 e Commonwealth of Massachusetts Title 5 Official Inspection Form all Subsurface Sewage Disposal System Form-Not for Voluntary Assessments : 42 Pitchers Way w_ Property Address ;Ns Eleanor Duffek Owyner Owner's Name _ information is required for every -Hyannis ✓ MA 02601 02601 n.t page. CitylTown State Zip Code Date of Inspection P11 r ,- Inspection results must be submitted on this form. Inspection forms may not be altered in any y way. Please see completeness checklist at the end of the form. O��dNtttln llt Or AI,. // Important:When filling out forms A. Inspector Information '�• 9�`�: 0? y on the computer, JAM ES m use only the tab James D.Sears _ key to move your Name of Inspector "z U: ;E cursor-do not Cawide Enterprises ; �*'•.� 4 use the return _ - - ^! '` ty T I� 'b�— Company Na key. 153 Commercial Street ''/ n sr I N �G�41 _l Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally 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 8-10-18 spectoes Signature Dat 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. t5insp.doc•rev.7/26J2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•page 1 of 18 �6i ge a5ed xed did 5 i,:EZ 8 60Z&Z l, bntf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name Information Is Hyannis MA 02601 02601 required for every 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: and 18 Chamber's.Box The system is a 1000 Gal.Tank D a 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): 5nsp doc-rev.7/2 812 0 1 8 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 2 of 18 92 a5ed xed dH 91,U 860Z Z6 6nV Commonwealth of Massachusetts Title 5 Official Inspection Form ii� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cant.): ❑ 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: 15insp.doc rev,P2612016 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 3 of 18 LZ a6ed xed dH 91l,U 860Z El, 6n`d Commonwealth of Massachusetts t; Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) ❑ 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 15insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 92 a6ed xeJ dH 9 b:£Z 8 60Z El, End Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 his less than 6"below invert or available volume is less than '/2day flow 4MC14106. ❑ ® 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 water supply 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 collform 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- ❑ ® 10,000 gpd. ❑ ® The system f ills. 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) 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.7126/20118 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 5af 18 6Z a6ed xed dH 9 1�:£Z 8 60Z Z 6 6r>d c Commonwealth of Massachusetts Title 5 Official Inspection Form t a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. CityrTown 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 C.4 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. 6. You must indicate"yes" or"no" for each of the following for alf inspections: 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 NIA) ® ❑ 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)] I 151nsp.doc-rev.712612018 Title 5 01dal nspectlon Form:Subsurface Sewage Disposal System•Page 6 of 18 0£ a6ed xeJ dH L I,U 2 tOZ Z I, 5rTV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owners Name information is required for every Hyannis MA 02601 02601 page. City/Town 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 Description: 1 Number of current residents: 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)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doe•rev.7I28/2016 Title 5 Offiaal inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 6£ a5ed xed dH 86U 860Z Z6 5rY Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name Information Is Hyannis MA 02601 02601 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 2. CommerciaVindustrial 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 occupancyluse: Date Other(describe below): 3. Pumping Records: NA 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: 15insp.doc•rev.MW201 B Title 5 Offical Inspection Form:Subsurlaee Sewage Disposal System•Page 8 of 18 Z£ a5ed xeJ dH 8I U 8 60Z Z 6 6171'd Commonwealth of Massachusetts Title 5 Official Inspection Form kN Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information Is required for every Hyannis MA 02601 02601 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Cl 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: Tank NA-Box&Chambers 2010 Permit # 2010 -4-24. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 21 Depth belowgrade: 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, eta): Pipeing is 4" PVC SCH -40. t5insp.dcc-rev.V26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 0 of 18 ££ a6ed xeJ dH 81:H 860Z 26 6rrf Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. City/Town state Zip Code Date of Inspection D. System information (cont.) 6. Septic Tank(locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 5, I, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 25" 1a Scum thickness 8n Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1711 Asbuilt-Plan-Tape How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 11"wlinlet cover at 8". Two inlet tee's,outlet No sign of leakage or over loading. Note: Tank to be maint Pumped after inspection. t5insp.00c-rev.7f26l2018 Tole 5 Olflclal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 bE a6ed xed dH 81,U 860Z Z6 6ny Commonwealth of Massachusetts �- Title 5 Official Inspection Form I I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Wa Property Address Eleanor Duffek Owner Owner's Name information is Hyannis MA 02601 02601 required for every State Zip Code Date or Inspection page City/Town D. System Information (cont.) 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.): 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 f5insp.doc-rev.M2612018 Tille 5 01dal Inspection Form:subsuAace Sewage Disposal system Page 11 of 16 I gE a5ed xed dH UEZ 8 60Z Z l• 6W Commonwealth of Massachusetts Title 5 Official Inspection Form ra Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owners Name information is Hy MA 02601 02601 Hyannis required for every State Zip Code Date of Inspection page. cityrrown 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 cf 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,): D Box is 20"x2D"-3' below grade wlccver at 10". Box is clean and solid wlthree lines out. No sign of over loading or solid carry over. 151nsp.doc•rev.7i2612016 Title 5 official Inspection Form:Sutsurfece Sewage Disposal System•Page 12 of 18 96 a5ed xed dH 6 VEZ 9 M Z 6 6nf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way u Property Address Eleanor Duffek Owner Owners Name information is Hyannis MA 02601 02601 required for every page City/Tcwn State Zip Code Date of Inspection D. System Information (cunt.) 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 number: 18 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: tsinsp.doc•rev.7126/2018 Title 5 official Inspection Force Subsurface Sewage oisposal System•Page 13 of 18 L£ abed xed dH 61,U 8 60Z 2 I. End Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is Hyannis MA 02601 02601 required for every State Zip Code Date of Inspection page. City/Town 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 is three rows of(ADS 36 units).Total of 18 chamber's stone less. Ck D Box camera out and prob area No sign of over loading 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.): I t5lnsp.doc•rev 7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1a of 18 g£ a5ed xe:1 dH 0Z£Z 8 60Z Z I• 5n`d Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owners Name information is required for every Hyannis MA 02601 02601 page. City(Town 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.): {I Mnsp.dx•rev.7/2&2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 or 1a 66 a5ed xed dH WEE 21,0Z El, 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form UTF1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Zf Property Address Eleanor Duffek Owner Owner's Name inforrnatlon is H annis MA 02601 02601 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 A IB f � o A-r= 13 /�-3= AL t5insp.doc•rev.VW2018 TiVe 5 Of lal Inspection Form:Subsurface Sewage Disposal System-Page 16 0115 0t7 abed xe:1 dH 03H 860Z Zl. 6nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments a 42 Pitchers Way wi ol Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells v 12' Estimated depth to igh ground water: 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: 10.15-10 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; T.H. on Design plan 10-15-10 12' no G.W.. Bottom of chamber's at around 4'below grade. Bottom of chamber's at 8'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7l2612018 Title 5Official Inspection Form:SubsLKace Sewage Disposal System-Page 17 of 18 i,t, a5ed xeJ dH 0M 860E Z6 5r1V Commonwealth of Massachusetts 6z Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Eleanor Duffek Owner Owner's Name information is required for every Hyannis MA 02601 02601 page. City/Town 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 I { tSinsp.doc•rev.712612018 Title 6 Official Inspection Form:Subsurface Smage Disposal System Page 18 of 18 Zt, a5ed xeJ dH ZEE 860Z Z6 5rYV Town of Barnstable Barnstable P r � o� pHlmericaC>�y Regulatory Services Department nn�uvsrnat.�, i634' Public Health Division m Q7 �0 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 O ply Thomas F.A Geller;Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70083230000251782947 8/03/2010 Sheila Bournival 651 Main Street West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 42 Pitchers Way,Hyannis MA was last inspected on June 22, 2010, by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Liquid depth in cesspool is less the 6"below invert or available volume is less than '/z day flow. • Static liquid level in the/distribution box above outlet invert due to an overloaded or clogged SAS or cesspool You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. ; Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town 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 A. General Information I f forms on the I computer, use 1. Inspector: I� only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (50.8)428-4028 S14454 Telephone Number License Number B. Certification I certify that I.have personally inspected the sewage disposal system at this address and.that the information;reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR15.000). The system: ❑ Passes ❑ Conditionally Passes ® Failsp, ❑ Needs Further Evaluation by the Local Approving Authority - ` ? 6/22/2010 Ins cto s S nature Date r'" The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,'and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispos System•Page 1 of� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 31 Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® El than depth in cesspool is less than 6" below.invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 t Commonwealth of Massachusetts W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 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 cM °y 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System•Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 42 Pitchers Way M Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® _Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3/2010 Date Commerciallindustrial 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 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 M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): `Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 104 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 5" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town 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 27" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 91, How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 42 Pitchers Way M Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: 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? El Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every 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 Stain lines over inverts 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.): Box is Ievel.Box has two outlet laterals.Evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 �M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.System shows signs of hydraulic failure.Stain lines observed over inverts in both pits. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts WX W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 42 Pitchers Way M Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch.Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately fe. 77L 8 �.t1. t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is required for Hyannis Ma. 02601 6/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 20'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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ' - Title 5 Official Inspection Form ell Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 42 Pitchers Way Property Address Sheila Bournival Owner Owner's Name information is Y required for Hyannis Ma. 02601 6/22/2010 x every page. City/Town 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 Z i t5ins•09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I TOWN OF BARNSTABLE LOCATION��T �� �'�y SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY-00-XsT%"do >000 LEACHING FACILITY:(type) ,00a11Z,0A7'io'(size) 9 _X NO.OF BEDROOMS OWNER .i' �/'�ow��® —To�ydZerA1�"rTifT�" a9o �. 30® PERMIT DATE: 00, ,00e,o COMPLIANCE DATE: Separation Distance Between the: raffia Ae,,4.7�"4! 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 \ C% 00 ti ® wo NC a No. a�l o L Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Moo.5al �&pgtem Con0tructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System Kindividual Components Location Address or Lot No. ®/i� ��`t � � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building s—P No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �- � gpd Design flow provided .�� gpd Plan Date �© —��/� Number of sheets /e Revision Date Title Size of Septic Tank 'l���'/T�ia• t� ®00 Type of S.A.S. Description of Soil 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 Certificate of Compliance has been issued by this Board of Health. Signed Date I Application Approved by LL Date /6— ; (— /0 Application Disapproved by: Date for the following reasons Permit No. ————Date Issued /V_;t/_/C) x -+.r-.--., No. �i 1L1 a Fee ,. t Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS i Yes. 3 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Z(Ppgici tioft for C-Ow5truction hermit J. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System Kindividual Components t Location Address or Lot No. �G% Q V Owner's Name,Address,and Tel.No. Assessor's Map/Parcel � s + y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: , Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.No.of Persons Showers( ) Cafeteria( ) Other Fixtures F Design Flow(min.required) -Tor gpd Design flow provided gpd '�- Plan Date /O — 105-'-X0 Number of sheets �'' Revision Date Title Size of Septic Tank +s:4"X�J'/r��' /'00 Type of S.A.S. � a/ 4.4+d/,,0 Description of Soil t , 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 Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date /G- a I h Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by ..eeA!?©�C-'�`r✓'X� at 5�— / � t .f ✓° , /' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o?f)j0_ Ll)-N dated t/0 Installer sJ�-otPy Gam°eAOF&Z 4/. Designer •Gt�f'd/,C� Q/1�,,�.}* ^/L! G • '. #bedrooms „"r'' Approved design flow ✓ gpd The issuance of this er//mit shall not be construed as a guarantee that the system wil -ff� ctiro�n as designnid._ C Date ��.1 U J Inspector C!� dp, ,may--" �d �"_. '�R.� 4q�:•�,'���"� �- r= �-eta-+��,=a€;.� - trr,� .... _ — �^ I� ). ——._ No Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ; Digo al &pgtem (Em5truction j3ermit Permission'`hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System locat'id at -:0Z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty i to comply with itle 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit n- Date C>' 1 , 10 Approved by OCT/26/2010/TUE 10:25 AM SandwichTownOffices FAX No, 1 508 833 0018 P, 001/001 Town of Barnstable' ' Regulatory Services Thomas F.Geiier,(Director PabIte Health WbIon Thomas McKeao,Director 200 Mih Street,)�yauws,IOTA,02601 Office:.508-862-4644 -Fax: 509-790-6304 installer&Designer Certi Cgjou Form Date- Designer: OVI.0 1M 1R rnstaller:. OYLLi0 � Address: . l t�14�11,� .Address: e4o z on fq �o as issued emir p to ix�st$ll a , date) xnslIler) septic system at used on design drawn b (address) Y f1• �� dated (designer) e fy tbat•the 8eptac system ze£ex aced above was in-As Zed substantiaU acd- -� nzx#irzg to 'sae dvsi w 'ch may include�mo7r approved,changes es such as lat�, � Y ' �`A g .�sjacahc�x di'the dt,slii bu&:o box and/or septic tank, I cent lhat the septic system r fimnced above was amtaAW vs►fth" . -Oi.cages'(j e, gzeater the 0 later reloca t ,u o the SASS or any.ve�rbica '.. —i)a'la4n�of y co7Q]pp �e o£fihe.sep#�° #e�oo}bnf i a accordance with State.&I.ocal;3eg�;1ations, Phn reels M or cued as bii t e y des er t6 follovsr. � 7AVID (IIIStauL'r'S,�''1gC28tlLTe-) 1$0 m n Na10aB . _ sRN}TA411A� • (D s Signature} ffix =.. afaapere� PIYIASk RETURN TO U i .&..�CA.)II� '�j ]OIC:- rf H DBURTAW CA-VrVp DD AM D�TZE- T ANK Q:HPaJl Septic/Design rCcrtficdivp or of� Town of Barnstable P# /31 ddc- \ � Department of Regulatory Services t� MAU Public Health Division '"�1039. n 3 �� 200 Main Street,Hyannis MA 02601 Date Date Scheduled_ o (� 6 .:,` ;, Time--�L--- Fee Pd. l�J Soil Suitability Assessment.,for Sewage' isnoral Performed By 1 �� C � Witnessed By: LOCATION& GENERAL FORMATION Location Address f��j T��G�GLJ' �l�i/y�/� Owner's Name TAB y Address Assessor's Map/Parcel: !� Engineer's Name NEW CONSTRUCTION REPAIR n Telephone#d Land Use Slopes Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well Drainage Way- —_ft 'Property Line —�_ft Other ft y SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands I`n proximity y to holes) Z Parent material(geologic) Depth to Bedrock ------------------ Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face ------------- Estimated Seasonal High Groundwater DETERNUNATION FOR SEASONAL HIGH WATER TABLEMethod Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: In. Depth to soil mettles: in Index Well# Reading Date: Index Well level` ..y(n, Groundwater Adjustment ft. Adj,thctor- Adj,Groundwater l evpl I Observation PERCOLATION TEST Date '!ihne,�� Hole# Depth of Perc 2 Tlme at&' Start Pre-soak Time @ ---�---:-�- Timc(9"-6") End Pre-soak f-- Rate MinJInch Site Suitability Assessment: Site Passed Sitc Failed: Additional Testing.Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you,must first notify the Barnstable Conservation Division at least one(1) week prior to beginning.; Division - DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil , Other Surface'(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. an istenc % ravel 12 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil, Other„ Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% ray DEEP OBSERVATION HOLE.LOG HOW# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) }' (USDA) a (Munsell)-- ' — Mottling (Structure,Stones,Boulders. Consiste c o Gravel .1 s DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency, Flood Insurance Rate Mau: . / Above 500 year flood boundary No— Yes y___ '. Within 500 year boundary No Yes E, , Within 100 year flood boundary No-ice-- Yes Depth of Naturally Occurring Pervious Material =j, Does at least four feet of naturally occurring pervi aterial exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth o'natlly occurring pe ous material? ' = E _ E Certification ' I certify that on V (date)I have passed the soil evaluator examination:approved by the Department of Environ otection and that the above analysis was perfo med by me consistent with the requir ining,exp ise d xp rience described in 310 CMR 15.017. Signature 1 Date to Io &�/— Q:\SEPT10PERCFORM.DOC 1•, 0 AT ION SEWAGE 4PERMIT NO. VILLAGE INSTALLER'S NAME A ADDRESS OR OWNER DATE PERMIT ISS DATE COMPLIANCE ISSUED �_ �� 4 !�.! (`- � �,j ,, �'+ �T � �� d � ��. � �� lTJ � � �� �� � �i � � �� � �� � ', w r� ��, ��� �. Qr . , � . is No. .{..-� FEs�..�.+4�4 . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ....................OF...............................................................-----...................... U u AppliPMfion for Bi"os al Works Tonstrurtiun Prmir Application is hereby made for a Permit to Construct ( ) or Repair^ an Individual Sewage Disposal System aa�i.... ,c _ Locatio Address or Lot No. ................... .._. .. •.. •---- ...................... ........ we. .............................................. " Owner �a Address .�.-��......................................... ......... .........--------.... .......----................................ ......................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria C4 Other fixtures .................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.....--......... Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x 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........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... a •-•-------•••----------•-•-•...................................................................••--.......................................................... 0 Description of Soil........................................................................................................................................................................ UNature of RepaiFs r rations—Answer when appli ble jJ�Ykt ---------- Agreement: Q .....-..... p ( ...... emu`- sue..._.. * , n7'!c---- .............. OD O �........ etl As d-i7 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the boa d of health. Signed.: /`� Date Application Approved By.......... - t. =� '' Date Application Disapproved for the following reasons:............................................................................................................... .........................•--•----•-......•---------•-------.......-•---......---.....------•---•-•---------------..............--•---------•-----------------•---•.----•-•--•-------•--•---•-----------. Date PermitNo..................................................._.._ Issued-....................................................... Date Z No....................... FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF.............................. Appliration for Disposal Works Tonstrurtion Urrmit Application is hereby made for a Permit to Construct or Repair..,K) an Individual Sewage Disposal System at ....................t, .................... ............. .......................... .................................................................................................. LocaticA-Addres or Lot No. ............. ................................................................... . ........ .. ... ......................... ...........zt'�� Owner Address .............. .. ........... .......................... .: .Z&..................... .................................................................................................. Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons...._........_._........_... Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow___.._:............................:._._.gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width........___..... Diameter................ Depth._.............. Disposal Trench—NO..................... Width_....__._...._._.._. Total Length__._........_....... Total leaching area....................sq. ft. Seepage Pit No................... Diameter........_....._..... Depth below inlet.__......_._________ Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by................................*-----------------------*................ Date........................................ Test Pit No. I...........:....minutes per inch Depth of Test Pit....__......__...... Depth to ground water.......___.._.__.._.___. Test Pit No. 2................minutesper inch Depth of Test Pit..._...._..._..___.. Depth to ground water..__......._._..._.:__._ ............................................................................................................................................................. 0 Description of Soil................................... ------------------------------------------------------------------------------------------------------------- ....................._ ........................................... ............ .................. U ............................................................................................. W .............. �0 . I- ........... - --------------------------------------------------------------------------------------- ----- ---- -- ------------------------------------------ ........... ------- U Nature r re oj Repairserations—Answer when ai)Dlicabie..._-.-_--�'. ------- wo A. ..IrvomeNo..... . ...... . .. Agreement: AS The undersigned agrees to install the aforedescribed IndividualS-ewage Disp osal System in accordance witli the provisions of T I A'11 5 of the State Sanitary Code—The undersi n6d fulther agrees not td-,1pl—b:ce the system in 9 i operation until a Certificate of Compliance has been issued by the board of health..,,. Signed .... ........................ .....1-4.�..................... .......................... -M Date ................................................ ......... ......... Application Approved By...... /-�_:_ V Date Application Disapproved for the following reasons:............................................... -------------------------------------------------------- ........................................................................................................................................................................................................ Date PermitNo....................................................... Issued_....................................................... Date THE.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL-TH ..........................................OF...........................................................I.......................... (9rdifiratr of Tompliaurr THIS IS TO CERTIFY, That the IndivWualSewage Disposal System constructed or Repaired by----------------------------------------------------A.............12044" ........................................................................................................ Installer at.. ------...............................J:2......P-(,-k'-S' t-,I L ............................................................................................................................................... has been installed in accordmrre')with the provisions of TITLE 5 of The State.;,Sanitary Code as described in the application for Disposal Works Construction Permit ............... dated........................................ ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION-SATISFACTORY. DATE................................................ ...... Inspector..................I................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... .......................OF..................................................................................... No, .............. ......................... FEEJ..i? Disposal Works Tonstr fora rquit Permission is hereby granted.........................4----------- ..............I------------_----------------------------------------------- to Construct )pr,4epa*r (X) an Individual Sewage Disposal System .........t at No.--......"#.-Z.... ..t............... ......................................................... --------------7--------------------I -,Street as shown on the application for Disposal Works Construction Permit No..................... Dated... ............�ml....... ...................................................................................................... Board of Health DATE.............................. ....... d .............. FORM 1255 A. M. SULKIN, INC., BOSTON Commonwealth of Massachusetts 0 Title 5 Official Inspection Form . _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every y page. Cityrrown 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brad J. White use the return Name of Inspector key. Bluewater Hld. Corp Company Name 285 Circuit Street Building C Company Address Hanover MA 02339 ' City/Town State Zip Code 617-301-3107 S14563 Telephone Number " License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of.on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310.CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails Needs Further.Evaluation by the Local Approving Authority 07/21/2010 Inspe s Si ature Date Th Sys m inspector shall submit a copy of this inspection report to the Approving Authority (Board of. He or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 i Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every 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) Sy tem Passes: I have not found any information which indicates that any of the failure criteria described in 310.CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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. El Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): t ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: 0 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pitchers42 P operty Address ay Prudential First Choice Owner Owner's Name information is required for every Hyannis MA 02601 07/21/2010 page. Cityrrown State Zip Code Date of Inspection 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 B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: • ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: —�,Prior inspection on Property indicates system is in failure. Prior report indicates high stain line in pit. Said leaching pit found dry with stain line approx 9"off of bottom of pit. Pictures attached r D) System Failure Criteria Applicable to All Systems: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..._ ..a::...._./: 42 Pitchers Way `- Property Address Prudential First Choice Owner Owner's.Name information is required for every Hyannis MA 02601 07/21/2010 page. City/Town State Zip Code Date of Inspection You must indicate "Yes"or"No"to each of the following for all inspections: Yes No 0 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overloaded or clogged SAS or cesspool El 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow B. Certification (cont.) Yes No El 0Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] ❑ 0 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..; 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every y page. Cityrrown State Zip Code Date of Inspection ❑ ❑ 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. C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑x Were any of the system components pumped out in the previous two weeks? ❑ ❑x Has the system received normal flows in the previous two week period? ❑ ❑x Have large volumes of water been introduced to the system recently or as part of this inspection? - 0 ❑ 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, including the SAS, located on site? ❑x ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑x ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑x ❑ Existing information. For example, a plan at the Board of Health. ❑x ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 �. Commonwealth of Massachusetts r Title 5 Official Inspection Form =' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 , 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is H required for every Hyannis MA 02601 07/21/2010 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Unknown Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 0 D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑Yes ❑x No Is laundry on a separate sewage system? [if yes separate inspection required] ❑Yes ❑x No Laundry system inspected? ❑XYes ❑ No Seasonal use? DYes ❑ No Water meter readings, if available last 2 ears usage d N/A 9 ( Y 9 (gp ))� Detail: Sump pump? ❑Yes FX1 No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 . Commonwealth of Massachusetts 0� Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 42 Pitchers Way V Property Address Prudential First Choice Owner Owner's Name information is H annis MA 02601 07/21/2010 required for every y page. CityfTown State Zip Code Date of Inspection 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? Oyes ❑ No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped approx 2 1/2 years ago Was system pumped as part of the inspection? ❑Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Recommend servicing tank 1 Type of System: ❑x Septic tank, distribution box, soil absorption system ❑ Single cesspool t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 < Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every y page. City/Town State Zip Code Date of Inspection ❑ 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): D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Septic tank is original. New leaching pit installed in 1994 per previous inspection dated 2003. Were sewage odors detected when arriving at the site? ❑Yes ❑x No Building Sewer(locate on site plan): Depth below grade: ®c.16" feet Material of construction: ❑cast iron 0 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): -�Building sewer is in good condition. Piping is schedule 40 PVC. Septic Tank(locate on site plan): Depth below grade: 811 feet t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every page. City/Town State Zip Code Date of Inspection Material of construction: ❑x concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) []Yes ❑ No Dimensions: 1000 Gallon H-10 precast tank 311 Sludge depth: D. System Information (cont.) Septic Tank(cont.) 26-1 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 8 1/2 ` Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): -pop Inlet and outlet tees are in good condition. No effluent filter in place. Recommend servicing septic tank for maintenance purposes. Liquid level is normal. No evidence of high stain in septic tank. No evidence of leakage in or out of tank. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 _�. Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 42 Pitchers Way M Property Address Prudential First Choice Owner Owner's Name information is required for every Hyannis MA 02601 07/21/2010 page. Citylrown State Zip Code Date of Inspection 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 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: t5ins•09/08 Title 5 Official Inspection Form: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 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is y required for every Hyannis MA 02601 07/21/2010 page. Cityrrown State Zip Code Date of Inspection 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 D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -ow 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.): -�Liquid level in distribution box is normal. No evidence of leakage in or out of box. Used sewer camera to check distribution box. Box appeared to be structurally sound. liquid level was at outlet inverts. One line entering box and two lines exiting. I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ;a Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is required for every Hyannis MA 02601 07/21/2010 page. Cityrrown State Zip Code Date of Inspection Pump Chamber(locate on site plan): Pumps in working order: Oyes ❑ No Alarms in working order: ❑Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑x leaching pits number: 2 @ 6'x 6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 9. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every y page. City5own State Zip Code Date of Inspection Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ----aw Leaching consists of two leaching pits. 1 original to system (Viewed with sewer camera) The other pit was installed in early 90's. Exposed newer leaching pit. Pit was dry at time of inspection with evidence of high stain approx 9"off of bottom of pit floor. Sidewalls appeared to be clean and untouched.Very minor signs of root infiltration. Older pit viewed with camera appeared to have stain line approx 12" from bottom of pipe. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): H 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 D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,y) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42Pitcrs ay Property rtY Ad Prudential First Choice Owner Owner's Name information is Hyannis MA 02601 07/21/2010 required for every y page. City/Town State Zip Code Date of Inspection 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.): D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: FXZ1 hand-sketch in the area below ❑x drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form < o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is required for every Hyannis MA 02601 07/21/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope 0 Surface water 0 Check cellar t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is required for every Hyannis MA 02601 07/21/2010 page. City/Town State Zip Code Date of Inspection 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 x❑ 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: -low +8Hand augeered through bottom of bone dry pit to a total depth of 12'with no indication of groundwater infiltration. Bottom of pit is at 64". This leaves at least an additional T-8" of additional seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist l� Inspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f , Commonwealth of Massachusetts g Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,vim., y`',Y 42 Pitchers Way Property Address Prudential First Choice Owner Owner's Name information is required for every Hyannis MA .02601 07/21/2010 page. Cityrroownn State Zip Code Date of Inspection Imo' System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file s t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMM ONWEALTH OF MASSACHUSETTS <,11 114-G EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i a DEPARTMENT OF ENVIRONMENTAL PROTE TION -____._...._..- _ I Ava 1 a Z003 ;TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`VAGE DISPOSAL SYSTEM FORM PART A MAP . // CERTIFICATION CIc'� T �, PARCEL Property Address: I C P/•S („ice LOT Owner's Name: Owner's Address: 4 � Qrs (,✓c Date of Inspection. Name of Inspector: (lease pript) Company Name: L WIZI p — tG Mailing Address: p p oZ G3.S g 06L 6 4.11, Telephone Number: o CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3.10 of Title 5 (310 CivIR 15.000). The system: Zp-asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ad 01 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 10,0()0 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. Notcs and Comments "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. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO�EINTS PART A /CE/RTIFICATION (continued) Property Address: rC hers t rt (, Owner: L4 Date of Inspection: C 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 teria 15.303 or in 310 CNIR 15.30�F exist. Any failure criteria not evaluated are indica t any of the ilure ted b--Io%v. scribed in 310 CNiR Comments: B. System Conditionally Passes: v Cme or more system components as described in the"Conditional repaired. The system, upon completion of the replacement or repair aspproved by the Board of Heal 1?3��"secdon need to belth,wilor l pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please The septic tank is metal and over 20 years old"or the septic tank(whether metal or nut) is structurally unsound,a chibits substantial infiltration or exfiltration or tank failure is imminent. System%trill 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 passspc'ction 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 him Obstructed pipe(s)or due to a broken, settled or uneven distribution boeer S level em wiltstnbution box due to broken or approval of Board of Health): pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed i Pass inspection if((with approval of the Board of Health): P Pc(s)• The system «ill broken pipe(s)are replaced obstruction is removed ND explain: Irage) oc i f OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �� i 7�e hf?r 5 ri?Nf f �G Owner: ( .teems je Date of Inspection: � 1 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 CbfR 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 if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm- provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 71. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L`�aZ 14cAe J (.✓oi�v Owner: a171L6a/ Date of Inspection: 1 D. System Failure Criteria applicable to all systems: You must indicate"yes,,or"no"to each of the following for all inspections: Yes /No/ -_ t/ Backup of selvage into facility or system component due to overloaded or cloa�/—/ Discharge or ponding of effluent to the surface of the ground or surface waters dueed to an overlAS or oaded tied or — ol clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or //cesspool y Liquid depth in cesspool is less than 6"below invert or available volume is less than%:day flow _ t/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed i /of times pumped p pe(s). Number �y 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 ftier supply or tributary to a surface / water supply. 1Any portion of a cesspool or privy is within a Zone I 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, perfornre ' DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t::.:. cne well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitro92 gen 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.] L lL(Yes/No) The system fails. I have determined that one or more exist as described in 310 CMR 15.303, therefore the system fails.The system owner should co tact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a lar-le system the system must serve a facility with a design flow of Io,IN)0 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 sy stem is within 400 feet of a surface drinking water suppiv - _ 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 IX-7,e 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 15.304.The system owner should contact the appropriate regional Office of the Department. with 310 CIVfR Page S of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART B CHECKLIST Property Address• TG Owner•. ply O �o/ Date of Inspection; /� 0 Check if the following have been done. You must indicate`ves"or"no"as to each of the following: Ye,V No t/ ZWere Pumpin information wasprovided by the owner, occupant, or Board of Health any of the system components pumped out in the previ ous ous two weeks Has the system received normal flows in the previous two week period ZHave large volumes of water been introduced to the system recently or as of this ' p� inspection Were as built plans of the system obtained and examined?(If theywere 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 po ding the SAS,.located on site Were the septic tank manholes uncovered, opened and the interior of the tank inspected for the condition of th baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum _ Wa s 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: . Ye no Existing information. For example,a plan at the Board of Health Determined in the field(if any of the fai lure criteria related to Part C is at issue approximauon of distance is unacceptable) [310 CivfR 15.302(3)(b)� t Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP NTS PART C ECTION FORM SYSTEM INFOPUN ATION Property Address: T� ,(-'t 4G4pr'( Owner: Date of Inspection: RESIDENTLI L, FLOW CONDITIONS Number of bedrooms(design):—3- Number of bedrooms(actual):. DESIGN flow based on 310 CNIR 15.203 (for example: 110 gpd x#of bedrooms): �Y Number of current residents:�_ Does residence have a garbage grinder(yes or no): //0 Is laundry on a separate sewage stem yes or no):- Laundry system inspected(yes or n [if yes separate Pete inspection required] Seasonal use: (yes or no): IVO Water meter readings, if available(last 2 years usage(gpd)): SumP Pump(yes or no):/0 Last date of occupancy: CO bENIERCIAUIND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap Present(yes or no):. Industrial waste holding tank present(,yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of ocelpancy/use: O T:rER t, x): GENERAL Il`1FOILNUTION Pumping Records Source of information: r9N✓l Pcj y f� Was system pumped as Da — (7 J vkW part of the inspection(yes or no): If yes,volume pumped;----gallons—How was quantity Reason for pumping: q ty Pumped determined' TY OF SYSTEM v 10 Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool —Privy Shared system(yes or no) (if yes, attach previous _ P inspection records. if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner), _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all c mponents, date installed if known)and source of info lion; r i Were sewage odors detected when arriving at he site(yes or no):/JQ Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �-//Gc 4pYs (,✓Q Owner: e Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 4 � Materials of construction: iron _440 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): Zlocate SEPTIC TANK: on site plan) Depth below grade: Material of construction:_concrete— _fiberglass fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy.of certificate) Dimensions: Sludge depth: '— Distance from top of ,�dge to bottom of outlet tee or baffle: Scum thickness: n/� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee e- How were dimensions determined: Po/e �C Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as r ted to outlet rove�evidence o 1 ge, etc.): in ti� in o1rly^ oyN % p �� , GREASE TRAP:!Y(locate on site plan) de: Depth below gra _ Material of construction: concrete meta! fiberglass_Polyethylene other 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 inte tv li d levels as related to outlet invert,evidence of leakage, etc.): -' �' I i I Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: oZ �'�p �f a Owner. ��2t�v� oar Date of Inspection: O-7 TIGHT or HO LD TANK:Z(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: ealIons/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.): ISTRLB G 1 w:. ., _ (if present must be opened)(locate on site plan) Depth of liquid level abov_ .. invert: t4o%M-1 I Comments(note if box is lc•.cl a;;d distribution to outlets leakag to or out of box,et .): egttai,any evidence of solids carryover,any evidence of So/'/t 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.): Page 9ofII • OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSU RFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART C SYSTEM INFORINIATION(continued) Property Address: T� "-�c�eor/ I,✓q� Owner: w2� Date of Inspection: /� p SOU,ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) lf.SAS not located explain why: TT leaching pits,number. .�((l �s70 t� t.✓ �� o'.t teaching chambers, number: �� leaching galleries,number: 0 n f leaching trenches,number,length: A0 Si y1117s �.� C%o j S- ,,.� leaching fields,number,dimensions: ��, �H.� of '� overflow cesspool, number 6 /w �v Siy"l innovative/alternative system Type/name of technology: — N��a��c F"„ �wz. Comments(note condition of soil, signs of hydraulic failure, level of ponding, p soil,condition of vegetation, etc.): CESSPOOLS: /" (cesspool must be pumped as part of inspection)(locate on site plan) ) Number and configuration: Depth—top of liquid to inlet invert: i)eptn 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.): PR1W:.L(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: `�✓!rt!S i /� C�r�G / Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. G' e 7 4- �oNse G O 3I Page I I of I I OFFICIAL INSPECTION FORD[—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z Owner. -j0 Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 16,/ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan mMcwed: 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 � gr u must sc 'be how You/lestabli hed the high and water elevation: G� T t�eC��'P � 1 0 F _ Zohe - G Cz t�O Q Q 4�y 6alow 6-re-de Je, L ,[� wvi9 20,1e- — G � AssEssoRs MAP : TEST HOLE LOGS ' PARCEL : NOTES: SOIL EVALUATOR � I . r FLOOD ZONE W(pit, TRESS : 1 ,11T 191ki), 1 1) The installation shall comply with Title V and Town of 8q' %►hoard of R EF ER E N C E:_ '� /! r DATE: 42 Health Regulations. PERCOLAT ION RATE: Z 41 � / 2) The installer shall verify the location of utilities, sewer inverts and septic 2y� , V2 components prior to installation and setting base elevations. iL 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first TH- I � _ _ TH-2 _ 3 two feet out of the d-box to the leaching shall be level. —�'C> j� , � ' 4) This plan is not to be utilized for property line determination nor an other P P Y Y ' /C purpose other than the propAed system installation. �✓�``�' Ln�1'wl ��-/b � 1 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H 10 septic components. LOCATION MAP 1,'T G ' �� 7) The property is bounded by property corners and property lines. bt4q 8) The property owner shall review design considerations to approve of total t design flow and number of bedrooms to be considered for design. Receipt n Ip 0_-I ,,� of payment for the plan and installation based on the plan shall be deemed h approval of the design flow b the o pp � y weer. 9) The existing leaching or cesspools shall be pumped and filled with material la nD kpy,��, �fi � 1� HID �{ � (,0ki per Title V abandonment procedures. Those within the proposed SAS shall �w l '� �1' be removed along with contaminated soil and replaced with clean sand per pb1 M _Gam►+ ��GY� Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. J� BEDROOMS AT GAL/DAY/BEDROOM -, 3370 GAL/DAY 12)The installer is to take caution in excavation around the gas line if such exists. 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation. MGAL/DAY x 2 DAYS - &bV GAL USE/6'00GALLON SEPTIC TANK ( x��-n► 00 SO I L_-ABSORPT I N SYSTEM • 4 q Q-1\/ `• c lit /�' +, . A_✓'7;A707 57Z1tjCP / r l i s: AF X`� ;i . / 6 17 5 •, - t t a �xo� o PT I C SYSTEM SECTION AI n"r z� 1y 419-4 If, �bovqc>y�lw 69 s� - /d -�w_ 5 ( -- -Y---- f\ � 21'1 _i_u5 �1o� t'�>� Z�,nO D-Box 2 GAL 2,T I I ' 77 27� SEPTIC Afo � '-� � SITE AND SEWAGE PLAN LOCATION : '7l� _P/7_ehio-� 6JqY PREPARED FOR : J /�j 465cZL-L)F c-�C M T SCALE: W DAV I D B . MASON 9� DATE:`U �'Zblb _ DBC ENVIRONMENTAL DESIGNS 3 DATE HEALTH AGENT EAST SANDWICH . MA W ( 508 ) 833- 2177 Z