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HomeMy WebLinkAbout0127 PITCHER'S WAY - Health 117 Pi' her's Way Hyannis .F/R A = 289. 160 f " j i 1 i C F A. k X M I ��C.✓ 3 1 i c ,, � 1 __ s 7 i _ ... L, � � .. � - - � �- . .., � ��, .. _ �- a,_ ,.�. ..��.�-�. . Commonwealth of Massachusetts ;p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Insp ction 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. f�a�u Important:When filling out forms fo P A..Inspector In ation on the computer,use only the tab a'r4/ key to move your Name of Inspector cursor-do not use the return key. Company Name PO tin ( Al Company Address rks T &1 a 641 — _ Od-6 Y.4 City/Town 0 State 'r f _� Zip Code Telephon oer License Number B. Certification I 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;�Passes- 2. m: 1. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspecto Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I Sinsp.doc•rev.7/26r20�6 TiJe 5 of�dai 1^soe ion=or:suosurtac a sewage osposai System-?age',of+.a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �- /� 17 rl7-a�ier-S a Property Address &1ZOwner Owner's Name Q information is // required for every Mn1s / 7 a 60/ oZ�i page. City[Town State Zip Code Date of nspectio C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P ses: l have not found an information which indicates h f Y es that any o 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: 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): t5insp.00c•rev.712612018 Tore 5 0-5o&inspection Pon:Sucs�race Sewage Disposa[System•?age 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments tie Property Address - r_.,, Owner Owners Name ea information is �f ,q l G 9' required for every ✓�4 .j /' / l�oZGO� of page. City/Town State Zip Code Date of I pectin C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health; safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: [5insp.doc•rev.7/26f2018 _ite 5 offiazi:nspeccn roam:subsurface sewage Disposal system•?aye 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Nort for Voluntary Assessments Property Address Owner Owners Name information is AA W/1�C7 / required for every G1✓I✓1 t 10 page. City/Town State Zip Code Date ofy spection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No / ❑ �,/ Backup of sewage into facility or system component due to overloaded or uu 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 ?26/20'18•rev. -itle 5'ti2i 11s-e=1 Porn:Subsurface sewage Disposal Sys' •Page 4 of la ;Sinsp.tloc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 1 TG h drS ( /24- Property Address, Owner owners Name N� S �/" 'y ��N7� a 6 information is required for every page. Cityrrown State Zip Code Date of 196pectionr C. Inspection Summary (cost.) 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 J LJ oq logged SAS or cesspool d_rcu depth in cesspool is less than 6" below invert or available volume is less L than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or C obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. C� 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. I [ Any portion of a cesspool or privy is within 50 feet of a private water supply well. LJ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 0,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) 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 0.4. Yes No C ❑ the system is within 400 feet of a surface drinking water supply C ❑ the system is within 200 feet of a tributary to a surface drinking water supply i C C 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 ;5insp.00c•2v.7262018 Tive s `da inspection=orr.:subsu-ace Sewage tisposal Sys.em•page 5 of 18 Commonwealth of Massachusetts -. Title 5 Official Inspection Form VSubsurface Sewage Disposal System Form -Not for Voluntary Assessments � l r7 C��s G✓'G Property Address Owner Owner's Name information is O► �� //� Q_)60� �6 required for every _ '/ y' page. City/Town State Zip Code Date of f spectio C. Inspection Summary (cost.) If you have answered"yes"to any question in Section 0.5 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 all inspections: Yes ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ H 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? �0 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 U 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: i 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 t5insp.doc•rev.'126/2018 Tile .ot5uai;nspe Lion?on:subscrrace sewage Disposal System•?ages of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address Owner Owner's Name informaequine for is od(00� required for every r // page. City/Town State Zip Code Date of Ins ction D. System nformation .1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3�0 Description: 0 Gld .TC C f�I'• (9 Soo 11oh c4ANs Number of current residents: 40 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes K�-�o If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes [ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: Date t5insp.doc•rev.7126/2018 Tice 5 tdal:nspecoon=crn.sucsur ace sewage Dispcsai system• age 7 of t8? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner s Name G information is 6 / i required for every a d1 r1 t Qp� Q a.6 page. City(Town State Zip Code Date of spection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available.- Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes; volume pumped: gallons How was quantity pumped determined? — Reason for pumping: t5insp.00c•nsv.7126/201-8 ?iue 5 catficial inspection.=om:-3=scnace Sewage Disposal System•?age 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lo2 4er-c "61 Property Address Owner Owners Name /� � information is A54 0 d 6 of 2/' cP b g required for every page. OitYRown State Zip Code Date of In pection D. System Information (cons.) 4. Type of S m: Septic tank; distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the i/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Iv ®ant nAL Ay v .S• S o2m3 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;4'0 ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Title 5 r"5aai inspection Fom,.sucsur`ace Sewage Disposai system-Page 9 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts P Title 5 Official Inspection Form r< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �� /� •/ Owner Owner's Name information is l required for every nl Ot 6� 0�60 page. City/Town State Zip Code Date of frApectioif D. System Information (cost.) 6. Septic Tank(locate on site plan): Depth below grade: feet Maten 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 or certificate) ❑pYes ❑ No Dimensions: 5 o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle /l/Orl-0— 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 - 0�� RGt C G-e How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): l/1 AA✓J d4' 0-eA- -c• . -7—ark, at4C_1s t5insp.dcc•rev.7/2612018 7 me 5 Oif.oal Inspection=o gin:Suosur"ace Sewage Disposal System•?age 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - of for Voluntary Assessments Property Address r_,, 41(/y Owner Owner's Name information is / ' A. 0j&0/ required for every page. City7own State Zip Code Date of Ins ection 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 ?iUe 5 Ica:inspacuon Pori:Sucsurace Sewage Disposal System•Page 11 of 18 t6insp.doc•rev.7126�2018 f Commonwealth of Massachusetts Title 5 Official Inspection Form dSubsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address f / Owner Owner's Name information is GN yl� %Q Do�6 0 required for every page. City(Town State Zip Code Date of spection D. System Information (cons.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): keo Depth of liquid level above outlet invert 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.): Jeve.,l r ,Je 5�Tfcti!nsoz Jon Fd n.Suosudace Sewage Disposal System•?age 12 of 18 5insp.doc•rev.7252018 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name A�f l "Ingpectio information is OJ6 a/required for everypage. City/Town State Zip Code Date o D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Soo Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeiaitemative system Type/name of technology: --- ---- ?age?3 of 1d t5insp.doc•rev.'/26/2018 'me 5 Q(5�a�!ns?e.�or.=cm:SuDS�rtac2 sewage Disposal System• Commonwealth of Massachusetts -. iz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - No for Voluntary Assessments � Property Address Owner Owner's Name information is W,� Q160/ a6 required for every A✓«'1 if f//`' page. City/Town State Zip Code Date of specti D. System Information (cost.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): O G w ! / 14461 4rop0� r /7/ O 91445 004 At, C1 r ft I,. t Gt 6 lu fy- 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.): 15insp.doc•rev.7126f2018 -iae 5�`.oai Inspecion=o:..m.Sucsudace Sewage osposai System.?age 14 of 18 Commonwealth of Massachusetts mqTitle- 5 Official Inspection Form Subsurface Sewage Disposal System Fo - Not for Voluntary Assessments m'�. �Z ' Coot��e Property Address Owner Owner's Name information is required for every 614t �(/ p page. City/Town State Zip Code Date of In pection D. System Information (cons.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, levei of ponding, condition of vegetation, etc.): i 1 t6insp.doc•rev.7/262018 Tine 5 Cffiaal inscecuon=o—.Scos,dace Sewage Disposal System•?age 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Id 7 4 �. Property Address G✓'r (�y Owner Owner's Name information is 4#161 U 60/ required for every V b page. Cityt7own State Zip Code Date of Insp ction D. System Information (cons.) 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 buildin heck one of the boxes below: and-sketch in the area below ❑ drawing attached separately I i Li I Paf+o � f.4 77 i I i Fro A/T I lid, I l t5insp.doc•rev.712612018 7i5e 5 Q`5dai inspi-acn=c-m:SUDSL"aCe Sewage Disposai System•?age 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface stem Sewage Disposal S F 9 ll p y o� Not for Voluntary Assessments Property Address Owner a Owner�Name information is /� 7required for every ✓1 7StatLeZjp Vd 6 0 a 6 page. Cityl I own Code Date of In ection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water Check cellar 1=l Shallow wells Id �T Estimated depth to high ground water: T y� 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) Lze Checked with to card of Health - explain: Pia u f- i Ale-f Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain.- You must de e how you as abiished the high ground water elevation: 5), G✓! w `� •— AID /OC w d. 4 aN, s S. 9c7z' -- ht!s . !'5 . 4S, IS oz� t1jE 61 o u 0 d6ndl -�- Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.dcc•rev.728,2018 —tie 5 3-,5aai,rspecoon Fa-:Suosur,"ace Sewage Disposai System•?age 17 of,8 V Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not f pr Voluntary Assessments Property Address 0 &AI Owner Owner's Name information is r^> required for every of J4 415 page. City/Town State Zip Code Date of Ins otion E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. Certification: Signed & Dated and 1, 2, 3; or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 allure 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 r a t5insp.00c•rev.7/26/2018 -.ve 5 0-.3oa;fnspeczon=or.suosur""ace sewage o-sposai system•?age t8 of 1s i No. C�Q/4 G 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Disposal *pstem Construction permit Application for a Permit to Construct(, ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ! '7 �ors- �A/ Owner's N e,Address,and T 1.No. �1 5, G, `Tr®va� q Assessor's Map/Parcel — o V 4 q LIll S'pA7P(iS' AIX /0-,9/ Installer's Name,Address,and/Tel.No. // Designer's Name,Address,and Tel.No.e,h Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures `� Design Flow(min.required) y gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) '(_ ��� ��t7 L 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. Si ed Date Z Z 7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. —no/q —O 5 7 Date Issued �— is \ No. j`7 G` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 5 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for ]Disposal 6pstem Construction Permit Application for a Permit to Construct Repair Upgrade( Abandon Complete System Individual Components PP ( ) P ) P� ( ) ( ) ❑ P Y ❑ P Location Address or Lot No. 7 1 ,�1l�p�s �q� . O--�wTnevTir's N e,Address,and T 1.No. P y' (ov .5 Sa fe f_ PVS AI X 1050 Assessor's Ma /Parcel Installer's Name,Address,and Tel.No. ! / Designer's'Name,e,Address,and Tel.No. PclC Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures //ll Design Flow'°(min.required) 3V gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Z d67aType of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S��- L eg W 7"7 L /�� 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 `y i' Compliance has been issued by j* h:e is Board of Heal h. Sd Date 2— 2. 7 Application Approved by Date" Application Disapproved by Date for the following reasons Permit No. --iC 5 7 Date Issued '�} 7 ---------- = - - .=)---------------------------------------------------------------------------------------------------------------- ",1 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 7t_;-e 1 Ct,7-f S <<u �Qi7( h�C/C at Z f(r��l00,r A4 ,,q noiej has been constructed'n accorrce with the provisions of Title 5 and the for Disposal System Construction Permit NOOed Installer A.b d if Designer #bedrooms Approved desigNflow ' and The issuance of this p shall of b construed as a guarantee that the system W 11 function as ddeesi�ed' "a ,/��jX, , Date Inspector % ,/E��/I)Il t�i I j� l�r "(� V"T 1 ----------------------------------- 6/------------------------------ ------------ --------- ----------------------------- No._ �y Fee /� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal &pstem Construttlon permit Permission is hereby granted to Construct( ) Repair` ) Upgrade( p) Abandon( ) System located at h017rs /fill/ - and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Date 2 �--7 �-O(Y Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal S stem Form-Not for Voluntary Assessments 12� Pitchers �Vay Hyannis MA f�operlyAddress Joseph Trovato and Rose Ann Zollino 3 Hyatt Lane Cromer Owne's Name . inforrmtionis Somers NY 10589 2/18/2014 required for every page. Ci ylrown 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. fmng out f:When A. General lnfornution Bing out forms on the conputer, use only the tab 1. Inspector. I foes to nave your O cursor-do not use the retum ryas of kispectcr Soo Martins may_ Accu Sepcheck a/f1�„ 11 Company Narre vf�l S. Dennis, MA 02660 Company Address 1�1 - CRylrown state Zip Code 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 CM 15.000). The system: ❑ PassesConditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �-S- t pectoft Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Lars•3N3 TidescmdalU�a om[Su6aufaee Saaaget)isposal System•Page totl7 ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address 'Joseph-Trovatol and Rose Ann Zollino 3 Hyatt Lane Cw ner Cw ner's Name information is Somers NY 10589 2/18/2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 Conditional) Passes: Y Y 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): Sz n lc IS k he l�e Steer (ed D/- l-,e,o /gCe t5ins•3113 Title 5 Official Impaction 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 127 Pitchers Way Hyannis MA Property Address ,Joseph Trovato and Rose Ann Zollino 3 Hyatt Lane Cw ner Cw ner's Name -- - requirationis Somers NY 10589 2/18/2014 required for every page. atylfown State Zip Code Date of trlspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled o even 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 re aced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system requ/inspetion ping more than 4 times a year due to broken or obstructed pipe(s). The system will pass if(with approval of the Board of Health): ❑ broken pe replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstructioved ❑ Y ❑ N ❑ ND(Explain below): C) Further Ev luation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the syste is failing to protect public health, safety or the environment. 1. Sys m will pass unless Board of Health determines in accordance with 310 CMR 15.303( )(b)that the system is not functioning in a mannerwhich will protect public health, safety nd 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•3113 Title 5 Official InspectionForm Subsurface Sewage Disposal System-Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address ,Joseph Trovato';and Rose Ann Zollino 3 Hyatt Lane Ow ner Owner's Name information is Somers NY 10589 2/18/2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unlessthe Board of Health (and Public Water Supplier,if determines that the system is functioning in a manner that protects th blic health, safety and environment: ❑ The system has a septic tank and soil absorption system(S and the SAS is within 100 feet of a surface water supply or tributary to a surface w r supply. ❑ The system has a septic tank and SAS and the SAS ' within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and th AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and a 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 ater analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates abs t and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provi d that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/day flow t5ins•3113 Title 5Official Irspection Form Subsurface Sevage Disposal System•Page 4of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address ---'and Rose Ann Zollino 3 Hyatt Lane Joseph'Tlrovato Cw ner ON ner's Name - information is required for every Somers NY 10589 2/18/2014 page. City/Town State Zip Code Date of Inspection B. Certification (corn.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ b 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 oft ng, in addition to the questions in Section D. Yes No ❑ ❑ the syste ' within 400 feet of a surface drinking water supply ❑ ❑ e 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 ou 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. t5irs•3113 TiVe50fficlallnspectionForm SubsurfaceSevageDisposal System Page5of17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address Joseph Trovato!and Rose Ann Zollino 3 Hyatt Lane Cw ner CW ner's Name information is required for every Somers NY 10589 2/18/2014 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? ❑ I 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) 16 ❑ Was the facility or dwelling inspected for signs of sewage back up? L61 ❑ Was the site inspected for signs of break out? ElWere all system components, etA� ing 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 ortees, 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: 3 Number of bedrooms (design): Number of bedrooms (actual): 33d DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): fts•3/13 Title 5 Official Ins pection F orm Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fur Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address Joseph Trovato-sand Rose Ann Zollino 3 Hyatt Lane O✓uner Cwner's Name information is required for every Somers NY 10589 2/18/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: r /D0() ql/m s� nG /?/(:f �dy tea C'L. c>li►.ar► s v� ?17N� Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? AJ l 4 ❑ Yes ❑ No Seasonal use? 9 Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: n ,� ( � `2 0 FT �ZZ` 0 - : )12- 100 FT3 = 90 ?S_0 Ku'; GU,* Sump pump? ❑ Yes , No Last date of occupancy: ft - Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): allons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding to resent? ❑ Yes ❑ No Non-sanitary was ischarged to the Title 5 system? ❑ Yes ❑ No Water m readings, if available: t5irs•3/13 Title 5 Official Iris pectionForm Subsurface Sewage Disposal System-Page 7of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Roperty Address - .Joseph TrovaltO nn and Rose A Zollino 3 Hyatt Lane Ow ner Owner's Name — -- inforrriation is m required for every Somers NY' 10589 2/18/2014 page. Cityfrown -State Zip Code Date of inspection D. System Information (corn.) Last date of occupancy/use: Date Other(describe below): General Information/V Q Pumping Records: d /l SIVXY 0� / v✓�1�41� Source of information: �.►s -e Was system pumped as part of the inspection? ❑ Yes I No If yes, wilume 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe).- t5irs•3/13 Title5Official Inspection Form Subsurface SevrageDisposal system•Page Bof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address Joseph Tr ovato and Rose Ann Zollino 3 Hyatt Lane Oru ner Ouv ner's Name - --- —— information is required for every Somers NY 10589 2/18/2014 page. City/town State Zip Code Date of Inspection. D. System Information (coat.) Approximate age of all components date installed (if known)and source of information: l� yp� s• s �(P�' add 3 ,&t-Dei"rK Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): l Depth below grade: feet Material of construction: ❑ cast iron g4o PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): N o LP ek k-S Septic Tank(locate on site plan): Depth below grade: feet Material of construction: Xconcrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3(13 Trde5 Official Ins pectlonForm Subsurface Sevoge Disposal Slstem-Page 9of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not'for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address. — — -_ Joseph Trovato 'and Rose Ann Zollino 3 Hyatt Lane ory ner Cw ner's Nameinfor tn is equiredfor every Somers . NY 10589 2/18/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) It Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? v "�' IaFX dhPQS11iQ� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e\idence of leakage, etc.): q i Apve� I s z/I/ .�J77c- tV lgn k Of eP7�/AaW M 44t I -e aYt Z LV1 -C7' Sd 1011Ws kaW 1P9/6Pof /h Z P i- ��PrQsT pyt-Ir Te- • 4f ,AC /IItT let AIRIOi!�5 w &�r�ivOfA; Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal erglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickn Dist a 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•3113 Title50Fflcial Ins pecdon Form Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Roperty Add ress . Joseph Trovato,and Rose Ann Zollino 3 Hyatt Lane Ovv ner O✓v ner's Name --- — - equiredfonrevery Somers NY 10589 2/18/2014 page. City[Town State Zip Code Date of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakag , etc.): Tight or Holding Tank(tank must a pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ etal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow gallons per day Alarm pr ent: ❑ Yes ❑ No Alarm vel: Alarm in working order. ❑ Yes ❑ No Dat of last pumping: Date mments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form Subsurface Savage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address --- -- Joseph Trovato'e and Rose Ann Zollino 3 Hyatt Lane Om ner Owner's Nameinfor — — is requirreedl for every Somers NY 10589 2/18/2014 page. City/Town State Zip Code Date of inspection D. System Information (corn.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert - z! r //7 V)t� 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.): J o Lit �k !S C/P,�i , /yd - VtdPycP OF lP �t6�L , Fox 4—h012.tiro �Tio1��Pve/ Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working or r. Yes ❑ No* Comments ( e condition of pump chamber, condition of pump nd appurtenances, etc.): * If pumps or alarms are not working order, system is a conditional pass. Soil Absorption Syst (SAS)(locate on site plan, excavation not required): If SAS not locate , explain why: t5irrts•3113 Title 5 Official Iris pectionForm Subsurface Savage Disposed System•Page U of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address — Joseph Trovato Jand Rose Ann Zollino 3 Hyatt Lane Cw ner O,v ner's Nam — requiredforevery Somers NY 10589 2/18/2014 page. Cdy1rown State Zip Code Date of Inspection D. System Information (corn.) Type: ❑ leaching pits number. ❑ 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.): � �„� � 1 3.z s Q e c ieo\ r a-y 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 ofconst ion Indica ' of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Iris pec;bon Fornt Subsurface Sewage Disposal System•Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address --- Joseph Trovato' d Rose Ann Zollino 3 Hyatt Lane ON ner ON ner's Name information is required for every Somers NY 10589 2/18/2014 page. Cityfrown State Zip Code Date of Nspection D. System Information (corn.) 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 hydrauli allure, level of ponding, condition of vegetation, etc.): i t5irs•3/13 Title5Official Ins pecfionForm Subsurface SevageDisposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address Joseph Travotto and Rose Ann Zollino 3 Hyatt Lane Qv net Cw ner's Name information is Somers NY 10589 2/18/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (coat) 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 7 W i 1 t, � 1Z%L3 q Jr t5ins•3113 Title 5 official Iris pectionForm Subsurface Sewage Disposal System-Page 15of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Pitchers Way Hyannis NIA Property Address —— --- — : Joseph Trovato'tand Rose Ann Zollino 3 Hyatt Lane ON ner Cw ner's Name information is Somers NY 10589 2/18/2014 required for every i page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Site Exam: [Check Slope Or Surface water [-Check cellar Ef Shallow wells 11. � Estimated depth to high 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: Date ❑_,/- Observed site(abutting property/observation hole within 150 feet of SAS) Lf Checked with local Board of Health-explain: es, •, �- {a �liz-3 Zoo Z ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: a C� Cdn��lssta►-- w You must describe how you established the high ground water elevation: 1 I _eS �— .Zf 2 - M CC,C. Ca"-&✓t G 10' L. '5 . /h /&S-C- q b 0 m Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 TiVe5 Official Iris pectionForm Subsurface Sewage Disposal Syslem•Page 16of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Pitchers Way Hyannis MA Property Address - - ,- Joseph Trovatoand Rose Ann Zollino 3 Hyatt Lane Oav ner Cw ner's Name — —- - requiretion is Somers NY 10589 2/18/2014 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist L� Inspection Summary: A, B, C, D, or E checked N Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Rr System Information—Estimated depth to high groundwater (Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5irs•3113 Title 5 Official lnspecfionForm Subsiaface savage Disposal System Page 17of 17 // TOWN OF BA.RNSTA.BLE LOCATION SEWAGE # -�7003- D�lv VILLAGE s/iS ASSESSOR'S MAP & LOT:1 /(D INSTALLER'S NAME&PHONE N0. S<dS —y20 Cp.17 A— ff SEPTIC TANK CAPACITY /D d 0 LEACHING FACILIT'Ys' (type) 2,,-sw 6,;,l /,rif G /c-A(size) �' �X 1-5 ' NO. OF BEDROOMS 1.13 BUILDER OR OWNER PERMIT DATE: f lS a 3 COMPLIANCE DATE: Separation Distance Between the: -Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facili ) Feet Furnished by ��a� y- i Y, �`!f. S`� i > •iF •w �_ __ r ,u� ? � � .. .y q `� � ���� � � � ;r�w - �^ ' ,S. r �,. ��, ,^,iy x�.: 1 c, ,� `� 9� .,.. d 1 �' - - r t. - � � . � � M 1 1 N • t 2C93 -02-6 i , No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for &gogar *p5tem Cottgtruction Permit Application for a Permit to Construct( )Repair( tjupgrade( )Abandon( ) ❑Complete System C' l dividual Components Location Address or Lot No.. 10 ezt7/ ya4l N;o Owner's Name,Address and Tel.No. Assessor's Map/Parcel 7 7 1 6 o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size 13, S-" sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 30 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Z—.ZUt2 y C494-1.ye-*-J Description of Soil cep- Nature of Repairs or Alterations(Answer when applicable) GiG( o,' C L Y Ttj 6y%,, U/t Z-SV0 4� G4-cw4e Y & ` .I fC t-e 0-s-x I T x Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by IfDate Application Disapproved for the following reasons Permit No. Date Issued t r: Fee . . Enter@d'.in computer. t y"THE COIV�MONWEALTH OF MASSACHUSETTS � ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Miopogal *p!tem Construction Permit . Application for a Permit to-Construcf( j Repair(grade( )Abandon( ) ❑Complete System E' 5dividual Co�ponents Location Address or Lot No. Z 1 10 j � Owner's Name,Address and Tel.No. ' i Gva7� E¢-ya,ti� Assessor's Map/Parcel R ANer Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ✓os�per �� /„)•� vS < E'v E• Nf1 die ��/�a.✓//2 ,S { 15 Type of Building: Dwelling- No.of Bedrooms Lot Size 1 3. SW sq.ft. Garbage Grinder( ) ' ' Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 7 0 gallons per day. Calculated daily flow gallons. Plan Date_ /���03 Number of sheets Revision Date Title li Size of Septic Tank -= X /tea Type of S.A.S. Z-3-0y9 -wr�ta J Description of Soil CUL y Nature of Repairs or Alterations(Answer when applicable) _ Qu t' l'eacA r C Y �'d►f Gv�i�+^� wt' 2 -S-00 a �f-/D eac4. G4A4.4 6,jr &,, ' jfei..e Cl-X-xl ,r2 Date last inspected- Agreement:, _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site-sewage disposal system- in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed ._ Date Application Approved by ------ Date Application Disapproved for the following reasons Permit No. Date Issued i Y 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 ' 7 _ f72 at Z 7 t IVe4to r- 6/ 0.1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 0,o 'Doa y dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will unction as designed. i Date I �� 1 10 Z Inspector V4 . -i 1v --------------------------------------- No.��� —/�Z. Fee !Es rL_q u3 C)26 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 11i, P00al *potem Co.ngtruction Permit Permission is hereby,granted to C"� Ponsttact( )Repair( grade( )Abandon,( System located at /Z 7 e�/Xc,4 e,--j and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. 'hProvided:Co struction must be.completed within three years of the date of this permit.�� Date: ��' d3 Approved by ` �i — i I TOWN OF BARNSTABLE LOCATION 1 7 p SEWAGE # VILLAGE �y ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.I SEPTIC TANK CAPACITY 1 D d 0 LEACAp G.1~A:CiLTIy: (h'Pe).�-.��o�r�•� /�rt� u�i�l size).— ize NO. OF BEDROOMS ( ) A BUILDER OR OWNER ,,7 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: itlaximum Adjusted Groundwater Table to the Bottom of Leaching Facilit Private Water Supply y Feet Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leachin fac-h ) Furnished by— ate � Feet � �JQ � lw • i 5/25/01 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, lla,,-t &4, S, ,hereby certify that the engineered plan signed by me- .dated concerning the property located at (Z.'1 a'j1,15 meets all- of-the _. following criteria: • This-failed system is-connected to-a residential dwelling only. There arena commercial or -business-uses associated with the dwelling. L • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude.this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation.[Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) o B) G.W.Elevation _ +adjustment for high G.W. 6 ("L¢97c-'2 rf, C -Zo�� DIFFERENCE BETWEEN A and B O, SIGNED DATE: a _ NOTICE Based upon the above information,a repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system -plans. I I q:health folder:p=6=p • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED FAILED INSPECTION ®EC 0 4 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 127 Pitchers Way Hyannis, MA 02601 Owner's Name: William Grant Owner's Address: Date of Inspection: November 11, 2002 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:289 Osterville,MA 02655-0049 Parcel. 160 Telephone Number: (508) 862-9400 Lot: 7 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 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs F er Evaluation by the Local Approving Authority ✓ ails Inspector's Signature: Date: November 21, 2002 The system inspector shall submt copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 127 Pitchers Way Hyannis, AM Owner: William Grant Date of Inspection: November 11, 2002 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. . *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND`explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes 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: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CIv11t 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply, the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 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: Yes No ✓ 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(3)(b)]. I 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 127 Pitchers Way Hyannis, AM Owner: William Grant Date of Inspection: November 11, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAIA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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 occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Oct. 3183-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 12" Material of construction: ✓ concrete _metal _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: 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 Pitchers Way Hyannis, AM Owner: William Grant Date of Inspection: November 11, 2002 . TIGHT or HOLDING TANK: None (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:. allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): { DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was broken down structurally and needs replacing. PUMP CHAMBER: None (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.): 8 i Page 9 of 11 • OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 Pitchers Way Hyannis, AM Owner: William Grant Date of Inspection: November 11, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6' 1000 gal. 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.): The pit had]'of water on the bottom. The scum line was above the inlet pipe. There were signs of failure. The bottom to grade was approximately 8'6". CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 Map:289 Parcel. 160 Lot: 7 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. A � y a a3 a� 3 a� 3a 10 Page i l of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 127 Pitchers Way Hyannis, MA Owner: William Grant Date of Inspection: November 11, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- 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 reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 8'6': Using Barnstable topographic and water contours maps, the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 t a , v 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property /•,2 7 4- �y /7Ly Ck Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: _Z Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they not ot available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. VAll system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of / sludge, depth of scum. . The size and location of the SAS on the site has been determined based on ex.isting. information or approximated by non-intrusive methods. NThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM -INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms _ number of current residents �Q_ garbage grinder, yes or no, _M5 laundry connected to system, yes or no _ seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: y Ll = g 1 bU 0 ��((aJA 5 0 C-c.✓ Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 4q e v% o r<<o y c o 1 1 %� �-� ! o,✓ v�s 1c. /c 4v System pumped as part of inspection, yes or no if yes, `volume pumped Reason for pumping: VType 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) Other (explain) Approximate age of all components. Date installed, if known. Source of informat' n Lis l(4� /b13ls3 ,mot �. s - b� , �f G4& -r.: ��. � � r 13-J.. r n 11� COP �j(o Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SEPTIC TANK: V' (locate on site plan) depth below grade: 1 material of construction: concrete metal FRP other(explain) dimensions: /X 6 / /060 1— sludge depth 1'2" distance from top of sludge to bottom of outlet tee or baffle 3„ scum thickness c" distance from top of scum to top of outlet tee or baffle If distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) / ✓ C e-, I et (:.-,> r o'.) G i o o r d J S i a ✓ as o ,be- lJ✓ M`o c !� aJ: /� h �Yr i n t v v t �i rc��.� W a✓ v�� o r�Q:�. DISTRIBUTION BOX: ✓ (locate on site plan) e / w ' J depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) a ✓ 1 / �l dAi 7 L A /'L Aito a o arJt2 PUMP CHAMBER: h- 9 (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, _ recommendations for maintenance or repairs, etc. ) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number �h< 6' X 6 L mat leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) i J s ci a dl V CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) v 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE E=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Frb h y3 o-aJx DEPTH TO GROUNDWATER �d-w depth to groundwater method of determination or app ro ximation: ITLA 4, C\0 7k" I 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? /V Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below .invert or available volume< 1/2 da} flow? Required pumping 4 times or more in the last year? number of times pumped � Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? h within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the ' SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well .water anal}, . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name �ro y/ (� i is w, 5 5,ce ;17 k s 7� a� Company Address 7 �/ �� ��5 S /C � u e v Rd Certification Statement I certify that I have personally inspected the 'sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. !L/911I one: have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signatu /J / Date Gv 7Dys Original to system owner Copies to: Buyer (if applicable) Approving authority go /a V n Design Calculations wEST LOT Y Number of Bedrooms: 3 MAIN STREET 19 ELIZABET H LAME LOT 9 Garbage Grinder: No � 1 3 cj PITCHERS WAY Leaching Capacity Required: 330 Gal./Day TOWN WATER � Leaching Area Required: 330 Gal./(0.74 Goi./Sq.Ft.)=446 Sq.Ft. Frost Ln. o� TOWN WATER tea' � I Proposed Leaching Structure: 1-25'L X 13'W X 2'D Leaching Trench 9~6 0) Leaching Area Provided: 479 Sq.Ft. Elizabeth Ln. °^ 6' sto_Ckad_e _ ---------._..-. ------. - Proposed Leaching Capacity: 355 d > 3 0 . �o 9 9,2 0' ---.- :---- - - - X 9 5 '--- ' 96,13' op ng ap tY= god 3 gpd. req'd SITE C.E 1 FIXD, 1 .7 Q 4' 5' 4' Sydney Dr. Sylvan Dr. Q 2„ OF 1/8" TO 1/4„ P �} PEASTONE (DOUBLE Simmons OF¢ X 98. 8' WASHED) 0 ® ® O Smith S Pond Rd. G N oQ ® © 24 MIN. t. Marstons Ave. I o Co X 2 H-10 500 gal. chambers 3/4" TO 1 1/2" DOUBLE WASHED CRUSHED STONE U Y A N N I S 98,49(', O � 98 4� S? � TRENCH CROSS—SECTION LOCUS 99,11' X 5 HOLE 98,25' 1 27 � NO SCALE q' — BOX NO, tC G NO SCALE C� \ {� C� 7,88' O o D NELUNG Cl 1 ,' deb EL•=99.13 O I CD O n / TOF fl. elev.=g2.1 � Q T,H, ##1 smt Q 1) 61 a 20 - �� 61' X paved driveway —, SS GENERAL MOTES LOT S 1. ADDRESS: 127 PITCHERS WAY, HYANNIS 2. ASSESSORS NUMBER,: MAP 289 PARCEL 160 3. DEVELOPER'S LOT: LOT 7 97,50; X AREA = 1 3,500± SO, FT. ��';-��._„-__ --� , 4. TOPOGRAPHIC INFORMATION WAS COMPLIED FORM AN Fr"j ON THE GROUND INSTRUMENT SURVEY. septic Se �1QCjK \ 5. MUNICIPAL WATER IS PROVIDED TO SITE AND O, SURROUNDING PROPERTIES, 99,24' X 1 1 49,0 3 6. REFERENCE PLAN: PLAN BOOK 85 PAGE 39 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS, 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. 1 - 25 'L X 13'W X 2 . 0' D Ie c c h I I g trench using '� t 40"DIAM,ACCESS MANHOLE ....-. -.. .. -....... --.. .-.... 1 29 H - 1 UJ 500 gal, chambers with 8- 5' 4 , of stone on sides & ends. CONSTRUCTION NOTES .° J 1. Contractor is responsible for Digsafe notification ® F=7 0 34" and protection of all underground utilities and pipes. LOT T 5 ---------- © O ® 24„ 2. The septic tank and distribution box shall be set _- level on 6" of 3/4"-1 1/2" stone. �I( WAY V 3. Backfill should be clean send or gravel with no 1 1 9 PITCHERS V V / 1 I STEEL REINFORCED PRECAST CONCRETE 2 H-1 0 500 gal. Chambers stones over 3 In size. TOWN WATER PLAN VIEW END-SECTION 4. This system is subject to inspection during installation SOIL. EVALUATION VU WATER by Glen E. Harrington, R.S. H-10 500 GALLON CHAMBER 5. The contractor shall install this system in accordance Date of Soil Eval.: November 23, 2002 with Title V of the Massachusetts Environmental Code Test Performed By: GLEN E. -IARRINGTON, R.S., CSE NOT To SCALE and the Regulations of the Town of Barnstable. Excavator: Joey DeBarros jJoey s Septic Service SITE A^ \VI USE ACME PRECAST OR EQUAL 6. Provide a Acme Precast H-10 5-hole D-Box and 2 H-10 500 gal. chambers or equal. N T2 Hole SCALE: 1 "=20' 7, No vehicle or heavy machinery shall drive over the �' 1 - septic system unless noted as H-20 septic components. DEPTH sots ELEV. BENCH MARKON C.B. 1 END. 8. Install gas baffle or equal on septic tank outlet tee end. ELEV.=100.00' (ASSUMED) 9. All existing inverts and site conditions shall be verified by contractor. 97.61 10. Existing leach pit to be pumped and leachate contaminated soil removed. oomp sand - > 6" 10YR3/1 C7,11' Bw 22" "1O'y�6/6d 95.78' c1 _ m-C sand 95" 10 R6/E C2 m-c sand 2 123' .5Y6/480.99 NO GROUNDWATER ENCOUNTEFED NOFMA� PROPOSED SEPTIC SYSTEM UPGRADE PREPARED FOR = EN 1CC WILLIAM H. GRANT ET UX o. TON co AT 070 127 PITCHERS WAY 0 "NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. l�q .S-{�QQ�C� 10' min. from *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. LEGEND A/i�^A BARNS TALE P\ ( iYANNIs), MA house to septic tonk Sepfc lank covers trust be Finished grade over system=2Y slope away within 6" of finished rode 5 HOLE ) EXISTING LEACH PIT TO BE PREPARED BY: Existing House g PUMPED & BACKFILLED TOP Elev. 99.13 DIST. BOX ` Exls , ADE Existing Grade Elev.-97.7't ,Q, R.S.0 I I EXISTING 1000 GAL GLEN E H ` R NG O N s ` S= 12' ,� .,. ,, .. ....,.�,�.,..,. 0 0 H-10 SEPTIC LEDA ROSE LANE 02 S=01 -' Level for 2" min. 2"-1/8" 1/2" 36"_Max. C e l l a t 3' EXISTING 6' s=.p1 doabe-wost ed store Top Peastone Efev=95 54' x 104.46 DENOTES EX STING { R TO N C A 02648 1000 GAL Ivl R S MILLS, M 6—t. Ei. Etev. 92.13' SEPTIC TANK n 16' in ert Ele .= 5.04' 1 ® ��® 0 H-10 m P o rn cs t�®o 0 24"^'^ Bottom of Leach ----95------------- EXISTING CONTOUR TEL: 508-428-3862 GAS BAFFLE OR EQUALII 1 25 Trench Elev.= 93,04' ° LEACH TRENCH FAX: 508-428-3862 5,7't ® DEEP TEST HOLE _ = 6" Of 3/4"-11,/2" STONE - ' - Bottom of T.H. 41 Ele .-a7.3s' APPROX. LOCATION SCALE: 1 "=20' DRAWN BY: GEH JAN. 8, 2003 -.- _.._ - SYSTEM PROFILE EXISTING WATER SERVICE w 6" of s/4"-11/2" STONE DATUM: ASSUMED FILE: GRANT SHEET 1 OF 1 Not io Scale c' i _-...___