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HomeMy WebLinkAbout0432 PITCHER'S WAY - Health 432 Pitcher's Way Hyannis. P s A._.291...017012 R I, 1 r d Commonwealth of Massachusetts 1p Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; C , Property Address 4rl Npi/cx v1 =a;; Owner Owner's Name information is ikil; �� Qa&© required for every —_ ___— r ' page. City/Town State Zip Code Date of Ins ection 11 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. inspector Infor tion 61# /33/ filling out forms a✓� Q0 // on the computer, use only the tab key to move your Name of Inspector cursor-do not vrt p use the return Company Name key. PO VIM �Company Address 'ef S / ✓!A ✓`� 4�1* o�6 City/Town State Zip Code t CSoy> 8 0 — 77�`� o Telephone Number 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 maintena of on-site sewage disposal systems.After conducting this inspection I have determined that the s ern: 1. Passes 2. ❑ Conditionally Passes 3. .❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's ignature 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. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Q V1-e..` ci 0 Owner Owne r's Name . ,p information is s401 .4 Da-&al p 30 /O required for every State Zip Code Date of nspec ion page. CitylTown C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. 1) System sses: 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: 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): Title 5 Official Inspection"roan.Subsurface Sewage Disposal system•Page 2 of 18 t5insp.doc•rev.7/26/2018 . Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C ICe Property Address pvtelav� Cwner Owner's Name AA information is required for every QhH�S A 0a(00/ �61 .30 /8- page. CityrTown State Zip Code Date of In ectio 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: t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4c-herS tt/Q Property Address 00ow-e, /a Owner Owners Name A4tqV14(; vinformation is /"� OP'&0! � v / 3F required for every page. City/Town State Zip Code Date of VfSpectio 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 ❑ ��Llll clogged SAS or cesspool El due or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.00c•rev.7/2 612 01 8 Title 5 Official Inspection Forth:Subsurface sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments //aj Property Address J9 �l©� //ct v? Owner Owner's Name information is ���� � required for every page. City/Town /Aigq State Zip Code Date of I specti C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded r clogged SAS or cesspool ❑ r,/ Liquid depth in cesspool is less than 6" below invert or available volume is less I� /flan❑ ' day flow uirired 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 u tributary to a surface water supply. ❑ pl_�Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ [G� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El 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 C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 0e,k; {� Owner Owner's Name / ,pinformation is A44t A7,4 6a-60/ OAV required for every - page. City/Town State Zip Code Date of Insn C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 official inspection Form:Subsurface Sewage Disposal system•Page 6 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,4 pvs (.,/G Property Address A4 UDOvte-/C. Owner Owner's Name , information is ��s oa 6 o/ required for every Gi / '/� page. City/Town State Zip Code Date of Insp ction D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 23o DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: l 6--//v y Saw? c ��µ Number of current residents: 0- Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes. No information in this report.) Laundry system inspected? ❑, Yes No Seasonal use? es ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L f 3a- 1 4c- 4Ie.-.S G✓4 Property Address Owner Owner's Name information is �4 /� ad 6 0�/-� a f required for every page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: C� Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 t5insp.doc•rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments YL Property Address O rtPi(a ✓1 Owner Owner's Name information is required for every / arLhls tA1,4 page. CityTTown State Zip Code Date of In ection D. System Information (cont.) 4. Type of Sy 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): 1 Approximate age of all components, date installed (if known)and source of information: 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/P El cast iron VC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.tloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i D- It'-�-'G AQ/S �✓� Property Address 7�0 we, a ✓1 Owner Owner's Name W/7 0 l �0/ information is A���s d• required for every State Zip Code Date of In ctionl page CitylTown D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material constructi on: concrete metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)) ❑ Yes ❑ No Dimensions: Sludge depth: li 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 C 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.): ------------ 00C CoH�,�r�✓t , Tire 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 t5insp.doc•rev.712 612 01 8 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address V00 He, 4 ✓� Owner Owner's Name information is q n4 0 /�� VaGo/ .30 /Q required for every r a page. CitylTown State Zip Code Date of Insl5ection D. System Information (cost.) 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 El metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Qr G Property Address o Loa Owner Owner's Name information is Xao jjVA4N f �/ 'g .70 f required for every page. city/Town State Zip Code Date of In pectin D. System Pnformatfion (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): L vex 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /J/J v / �v / information is 141 f. 0.160 / required for every 4 — page. City/Town State Zip Code Date of In ection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: lJ �,✓ S�-o 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: -- --- t5insp.doc•rev.7/26/2018 Titie 5 official Inspection Form:Subsurface Sewage oisposar System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address O v�14 Owner Owners Name information is aHy�J oa required for every page. City/Tom State Zip Code Date of Ins ection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A42- St 5#4s 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u — Property Address 0 / ONeiIG ✓I Owner Owner's Name information is /—/C14 0 4l f A'A �l r D/ � "so grequired for every O� ( page. City/Town State Zip Code Date of!nspecfon D. System rnformation (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions - Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address O �Q tiJ Owner Owner's Name �j Q information is //i yd-601 C�I :Zt required for every A✓It4 s page. CitylTown State Zip Code Date of Insp ction D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of sewage disposal system, including ties to at least two permanent reference landmarks or nch larks. Locate all wells within 100 feet. Locate where public water supply enters the buil Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ;� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ll 3c�- r i -c, e.-s (4/4 Property Address / Owner Owner's Name J) information is / n Q 7 Q required for every ` G'i 0 Od-&0 page. City/Town State Zip Code Date of Inspe tion D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells � I�f 3 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 ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked with local Board Qf Health- explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describ how y u established the high ground water elevation: v j.¢ /o J,4 h d(.reJe-If— Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp-doc•rev-7/26/2018 itle 5 Official inspection Form:Subsurface sewage Disposal system•Page 17 of 18 f c Commonwealth of Massachusetts I oTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w"O' LID- Property Address Owner Owner's Name information is 4 Qa6 Q/ required for every Q page. CityFrown L;� State Zip Code Date of I iorf E. Report Completeness Checklist Complete ail applicable sections of this form inclusive of: 7A. I pector Information: Complete all fields in this section. rtification: Signed & Dated and 1, 2, 3, or checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F ure 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 t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 18 of 18 sa 212 Z COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I d DEPARTMENT OF ENVIRONMENTAL PROTECTION d� ReC11-:1VED FEB 0 8 2005 TOWN Or BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION AF Property Address: 432 Pitchers Way ARCEL, � � 0 I Lo Hyannis,MA nT Owner's Name: Ms.Henrica Williams Owner's Address: P.O.Box 1573 Hyannis,MA Date of Inspection: 1/5/05 Name of Inspector: (please print) Mr. Carmen E.Shay Company Name: Shay Environmental Services,Inc. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 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: XX Passes Conditionally Passes ��P�,tH�Fti1Ass90 Need r E luation by the Local Approving Authority CARMEN tiN s Zi z E. o SHAY Inspector's Signature: Date: 1/5/05 �, a �RTII ���P The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea �F5 INS 9 ;i DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,00 i. 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. 'r Notes and Comments 2' effective depth available at time of inspection in Leach pit#1. Evidence of liquid level being 6" higher in Leach Pit. ****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 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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: Tr, r .,.. 2 � .i Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 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: t A 1 Page 4 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site'? XX _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of t he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? XX _ 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 XX _ Existing information. For example,a plan at the Board of Health. XX _ 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 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 86,000 gallons—2003/ 112,000 gallons in 2004 Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL 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: None Available Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool XX 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) s' _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 7/13/83—per BOH Records Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron XX 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: XX (locate on site plan) Depth below grade: Cover 6"Below Grade Material of construction: XX 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: 5' x 8' 1,000 gal. septic tank. Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: '/4 inch scum laver noted 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: 18" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural cesspool was ok. 4" PVC Tee present at inlet end. Outlet Baffle present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(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.): ... ., 1 , r ,,,,.- 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 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/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: Present (if present must be opened)(locate on site plan) 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.): No evidence of cracks or carryover. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions:_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Excavated cover and inspected pit—Yeffective depth available in pit. No evidence of past hydraulic Failure noted. Liquid level has been 6" higher than at time of inspection. 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): T . .„� 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: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 115105 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. PITCHERS WAY Water!Line ' I ' I Swing Ties: A- Cesspool— 17' B- Cesspool—31' Exist House A-D-Box 28' Deck (3 Bedroom) B—D-Box—3 P IA B I A- -Leach Pit-28' B—Leach Pit—42' O 1000 Gal Tank D-Box Leach Pit r .,,.,,.,.,,,. 10 Page 11 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 Pitchers Way Hyannis,MA Owner: Ms.Henrica Williams Date of Inspection: 1/5/05 SITE EXAM Slope Surface water -'h mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water Over 15' 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: XX Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Ouadrangle of USGS Map,MA GIS and performed GW adiustment calcs. Per Barnstable GIS: Elev.of Ground=34 Feet Elev.Of Groundwater=25.3 Feet Elev.Of Bottom of Leach Pit=27 Feet Therefore: 27—25.3 =�1.7 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well MIW 129: 5.3 feet Adjusted Groundwater Separation=20' +5.3' =25.3' feet Grade=Elev. 34 feet Leach Pit D-Box Bottom of Leach Pit=Elev.27 feet Tank Adj. Groundwater=Elev.25.3 Commonwealth of Massachusetts . Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Pitchers Way M Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ' rya ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/10/2009 � Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is p 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. [Al � I A 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis, Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed - ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines.in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for colliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. } 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for ail 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis " Ma. 02601 4/10/2009 every page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. . t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distribution box and one 1000 gallon leaching pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2007:162,000 g ( y g (gpd)): 2008:15,000 Detail: 2007:444 gpd 2008:41 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 4/10/2009 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 0 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5•`'y 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Pitchers Way M Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gl. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Pit had 2' of water at time of inspection.Stain line is 38" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction` Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/68 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 117 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size zoom Out ®In A leICU rR ry MEN . _. _. xi; _ k yRy _-- ...................................., ....................._.........................._................_....................................._... Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER r—wrinhf)nnj;-,)nn.Q Tnuin of Ramefahle AAA All rinhfc meant, liffm//ixnxnxi tntxrn hnmetalilp ma 01 7017Rr A112/7!1l10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 25.6' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 432 Pitchers Way Property Address Scott A. Parker Owner Owner's Name information is required for Hyannis Ma. 02601 4/10/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION z F ro� C aq �< W � o ��M Spey TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 0 �` o Owner's Name: KEVIN SANDERS Owner's Address: 432 PITCHER'S WAY HYANNIS, MA 02601 ���� Date of Inspection: 12/6/02 �® �c 2 ` ?00 Name of Inspector: (please print) JOHN GRACI T��yryUF Z Company Name: SEPTIC INSPECTIONS '�� ' �Fq4 ti�pSTge�F Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, 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: X PasjFuE _ Cons _ Neeuation by the Local Approving Authority Fail Inspector's Signature: Date: 12/G/02 The system inspector shall subhis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. { Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSfEM'S USEFUL LIFE. ***'This report only describes conditions at the time of inspection and under the conditions of use at that time.'Phis inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a .,Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped TWO YEARS AGO BY OWNER. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A ..Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined? If the were not available note as N/A P Y ( Y ) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out`? X _ Were all system components, excluding the SAS, located on site '? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 4 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)): nix �cQo—1 Sump pump(yes or no): NO l �s Last date of occupancy: n/a �b as�3 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: TWO YEARS AGO BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 20 YEARS BY OWNER 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: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Page 8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PIT,APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 6" OF LIQUID IN IT AND STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 6" OF LIQUID IN IT.BOTTOM IS AT 9 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a A Wage 10 of I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1'roperty Address: 432 PITCHER'S WAY HYANNIS, MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 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. N v INLI � I IL . . 1 M Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: 432 PITCHER'S WAY HYANNIS,MA 02601 Owner: KEVIN SANDERS Date of Inspection: 12/6/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. TOWN OF BARNSTABLE LOCATION AcVar s WC4 SEWAGE # 3,2, 4123 VILLA OF.-- lt1`S ASSESSOR'S MAP & LOT�gi-Oi 01A INSTALLER'S NAME&PHONE NO. C )OCkt A Can ` SEPTIC TANK CAPACITY OCO CkCAL f LEACH NG FACILITY: (type) 17MC V( \2c\- (size) (D X(0 NO.OF BEDROOMS,, BUILDER OR OWNER PI RMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) P, Feet Furnished by f rQ�u-A i:�" 00- C2r cr uo h � `4``' TOWN OF BARNSTABLE LOCATION c' SEWAGE # VMLAGE ASSESSOR'S MAP A:`Tn INSTALLER'S NAME&PHONE NO. -SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) ` JV u NO.OF BEDROOMS' _ A/tn)n BUELDER OR OWNER SandaV PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: +. Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by < n MCI A-6 ZZ ,i AG 2 A-0'Z 1 LOC T I0 SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS I U I L D E R OR OWNER DATE PERMIT ISSUED / 3 DAT E COMPLIANCE ISSUED 1��3 a � i . II 61 �t o i . No.........P.` -' FES..... ....................... THE COMMONWEALTH OF MASSAeHUS2#TS BOAR® OF HEALTH �cw� ..... OF........ �1.. ................................................. Applira#ion for UhipmFal Workv, Cnnnitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ocation-Address or t No. �1 w.� .. .....l�vw...is.................................. Owner Ad•ress ......................................................... Installer Address U Type of Building Size Lot../_i� ___t......Sq. feet Dwelling—No. of Bedrooms..........Z—............. ...___._..Expansion Attic ( ) Garbage Grinder (PL4 ) Other—T e of Building No. of persons............................ Showers — Cafeteria Pq Pq Other fixtures -----•----_----------••-------------------•-----•---•••-•---•-•--•--•------•--•••-•-•---••----••-•-••••---••----....-----.........._...._......-_.. W Design Flow.......Ll ..............................gallons per person per day. Total daily flow---jaa�............................gallons. WSeptic Tank—Liquid capacity 11MIC..gallons Length_.__ lC_. Width`t.Z42__.._. Diameter________________ Depth.S_.�...__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......t............. Diameterk .X_% _ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1............minutes per inch Depth of Test Pit..._/d........... Depth to ground water_______________________. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Pa ...................................••---.. ......., O Description of Soil--- -3---�aa. ;,v ci�- r�........ 3.' ............................................................ W •--•-•-•-•-•-----------------------•-- ••---......•---••-•----.....-•----•-----•....-•-•-----•---••--------•------------•-------•-•-----•--•--•--•-••••--•••-•-----•---•-•••----•--•.........._.......-- UNature of Repairs or Alterations—Answer when applicable...................................................•._......................................... ----------------------------------••----------------•------•---------------------------.........-•-•-••------------•----------------------------••-•---•--••-•---••-•----••-•-----------.......----..... Agreement: The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of H."Tl-�. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued b the b•par of health. igned•. .............................�............. Application Approved BY .............. = . Date Application Disapproved or a following reasons:................................................................................................................ -------------•----------------------------------------------------------.... ------------ --•------•-----------------------------------------------•---------------------- Date PermitNo......................................................... Issued....................................................... Date No.................- - Fps........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF k ."—KXc��'E- ........................•--•---------••--.........__.............---••--• Appliratiun for DiupouFal Works Tomitrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Mere- .:........ --..........._. --------------...---•------------------ •------•------- ocation Address e-h or Y°t No. Owner �tF ......................I............... - ......................................... .............................................� nstaller Add. ........ .................. ress � Q Type of Building Size Lot../.. ......................Sq. feet U Dwelling—No. of Bedroo -------------------- Attic ( ) Garbage Grinder ( ) 0•I Other—Type of Building ��""'I........ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures -----•--•-------------------•----•--------------------------------......-••••-----•---•--••.....: ;; .......-................................. Q W Design Flow•.•....'1 u...............................gallons per person er&y. Total cjaily�flow......."`.�?...._................__._..A99T. 0: Septic Tank—Liquid capacity! `'.gallons Length.�_$r°�"__...... Width`<E.2� ...... Diameter---------------- Depth............... Disposal Trench—No..................... Widtth....... ........ Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No......j.............. Diameter......' ........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................i •-------- Date........................................ 14 ,aa Test Pit No. I..__�......minutes per inch Depth of Test Pit.... ' ........._. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x l . .. 7 s ....._._ r .. �----•�p---------------------------------------------- Q i �ta F7- ��/.......��/oZ i i c`(,.F;i Jy� Description of Soil---------- �f------------------------••----........-- ------------------ ... x0-1 �ei!....,-•------•----------------••---•-------------•-••---•-....-•--------........-----------•----------------•---------------------------•--------------•--------...--------• U W -----•----------•-••----•---....•---•••-----••-•----••-----•-------------------••--•-•-----•-•--••-•------------------•-•--•--••-------•--•---------•••-----••---------•••••-•••._............-•-------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sa 'tary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h een issued by th boar of iealth. SDa Application Approved B Ifollowing _ 1_._r_ ------•---- PP PP y--- L• e , Application Disapproved reasons-----------------------------•---------------------------------•--------------------------------...._._....•••- ..----•-----•.......................................................................................................................................................................................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD' OF HEALTH ..........................................OF..........__.......­...... ............ Trrtifiratr of oh IS���CE 7IFY, That the Individual Sewage Disposal System constructed ( for Repaired ( ). by ... �' x'l --------------------­---- at .._..._._.... staller 4.•---•-••••-- ----------s---- a .• - has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod a/..,;ri ed in the application for Disposal Works Construction Permit No. __. _,.. dated ... 3 1--------------- z- ... THE ISSUANCEOF THIS CERTIFICATE SHALL NOT BE CONSTR AS GUARANTEE THAT THE SYSTEM W ),INCTION SATISFACTORY. DATE... �11,1 ............................. Inspector.. ..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............•---..... FE �l................. 0 ��i�a� riun rrntt Permissionis-hereby granted- -!----•-•-• .. —--------------•-----------•---------------...._........._..-•----•-•-•-----=--•--.....---•-••-•-•---.. to Constructer Repair (,,Tan Individu ewag !Ss l System � � '' at No.- '0 j ? v 1 r = -^ .. .................. `Street as shown on the ap 'catio for Disposal Works Construction Permit 113131 . --- Date _. .. .fir.. .................. ............................................ •-----• ------------............---•--._.....--••••.... /HOBBS oar FIealthDATE..---- -- -- --- -••-•----------------•----------•---------FORM 1255 & WARREN. INC.. PUBLISHERS SOIL LOG SITE PLANNO. 1 / O NO . 2 1 1 4/ / : 1 4 i r SAntf;Y 2 - - — 4 TOP OF FOUNDATION EL.: loo' - 5 UME © Z ' Abovr RoAr 5 MAX Coo P_ Ni J •,, ------- 8 ch'�-TE C'� t sZ S j --- Co�f�i Gov _ - 97� g - -, IN EL IN.EL � •� s, �, l f � •-T�N EL. 1 �� Q = _ - ra_ Tom"�•J � • - 2 COVER 1/8 3/8 WASHED STONE I•� IN El. INAL. L �, D/B W/ s„ SUMP `° I ��9n b;. ° ;.�.�- 3/4 1 1!2 WASHED STONE _ n6 w,:: 13 _ 4 LIQUID LEVEL - ° , % ' -- ` a Jo 14 �) • a• �.__� _� �` ° ' G• EFF. DEPTH _ r _ n b15 PERC TEST RESULTS PRECAST SEPTIC TANK WITH ( ^� o PRECAST LEACHING PITS PERC RATE CAST IN PLACE INLET AND �i � -T- a El. ?, _ NO_ SIZE : —�_ U��� 7��'_ I��r� f l WHITNESSED BY . -?� ; f)- OUTLET T 'S PER TITLE Y -� t h t ! BOARD OF HEALTH SIZE : '�` (wG x 1 f� v� ` 8" 1 ��- bIA . DATE rJo � - a 0IA. PROFILE OF PROPOSED SEWAGE SYSTEM SYSTEM DESIGNED BY THE TOWN OF __ _r REGULATIONS AND N STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE = 1/4" 10 ., _ - L�-r t N . B . 1 . All PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 2. All PIPES SHALL BE P SLOED 1/4 PER FOOT EXCEPT FOR N► THE FIRST 2 FEET OUT OF -THE D / B WHICH SHALL BE LEVEL 3. DESIGN FLOW BEDROOMS AT 110 GALDAY PER BR . ._- GALIOAY SEPTIC TANK SIZE _____ -__ X — GAL___ . USE -- G AL. W1 -, ' GARBAGE DISPOSAL _- n Q p.F .., ;F,. ( , LEACHING SYSTEM : USE � i.�-�f:z�-tff� t-r.r.. �� �,�y �F� L _ OF Fn w aF EFFECTIVE AREA : SIDE I )ie' x x 2.5 = 3&, %�_ - BOTTOM - TOTAL FLOW _ _ L�` i LA tcN TOTAL REQ D FLOW — X -' IM1 GARBAGE DISPOSAL � o - � RESERVE FLOW 6AL/DAY__ . REFERENCE PLANS : _ . h - - APPROVED BY BOARD OF HEALTH DATE • r .��__.___._ �_ ...._._ - --- _ .._._-.. ...__�..__._ �Q �� PROPERTY ; �1 �� �•� � � ���. �� �� }�� ..�1�c� _ --._..�-_ . _. _ t P,cH OF MAs "1 -, 'vOtt ��1►"�1:�L�L i..� �:�.0 t��_.__ . • 4 r 5...Jt-_.t , )_ i I