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Home My WebLink About0653 PITCHER'S WAY - Health 653--Ri#cher's,Way., '.,Hyannis- P P 1 i i v No......JF.....�. .............•. a THE COMMONWEALTH OF MASSACHUSETTS OARD F HE L \ X:�OB filaf .........OF.. .... _.-..................... Appliratiun -fur Uiupuual Works Tomitrurtiuu Vrrmit Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal syst% t ----------lr� - ------------•-•--.. ..... ...w�.`- �..................................................... ` Loca' Address or dot No. - -------•------ -• .................................... ...............--- ----•----- ............................................. 9 ner Address ...........l r-.4Y ------..17. �� .-- •-••--------•----- -- -' = Installer Address �j Type of Building Size Lot./1 Q._7 _---Sq. feet Dwelling—No. of Bedrooms.._ -----------------------------------Expansion Attic ( ) Garbage Grinder ( ) `1 p-, Other—Type of Building -------------------------_ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ---- - -•- - ------------------------•----------------------------------------- ---------------------------------- W Design Flow.....5 .............................gallons per person per day. Total daily flow________-_---a_®.-................gallons. WSeptic Tank—Liquid capacit/Ions Length................ Width------I........- Diameter................ Depth.-.._____-_-_-- x Disposal Trench—No--------------------- li................. al Length__ ___.__. .__._.. otal leaching area_.___.__........___.sq. ft. Seepage Pit No...... .......... :____-._ t._...____________... otal leaching area-- Q._. sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed bY........................................................................... Date--------------------------------------.. a W Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-------------------- f, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-._.--._-__________---- 9 ------------------------------------------------------------------------------------•---•----•--------------------------------------------------------------- 0 Description of Soil______________________________________ U --------------------------------- � °ESA.............................................�:� ��AVC-t �®.. - -------------------------------------------------------------------------------------------- W U Nature 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in 1 operation until a Certificate of Compliance has been issued by th board of eal Signe ---•• •--- -- ----�-�--------�----- ---��-- ----- . Date ------ Application Approved BY•---- ..................•-•-----•-..... Date Application Disapproved for t tie following reasons:.... ---------------- .......................•-•--•-------•-----•------._...--------•-•-••-----•-----•--•--•----•---------•--•-•-- •---------•-•--•--•-•--•-----------------••--------------------------------------------- ` 7 ate Permit No.------• v�1-------------------------------------- Issued....l-��.��_�__.�........;..=.............� Date — ----------------- i ' _y..; Fine /-: ...............- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .,* / '---------------------------------- Appliration -for Mixyla ial Eorks C utustrurtillit Prrnit Ajoi&tion is hereby'made for"a Permit to Construe or Repair ( ) an Individual Sewage Disposal System at r% /. � '�-��------•---_____- -•-----r/S!-r min.., .......................... /71 JJoX TornAddress or Lot No. l Ale�l�i+. / 7 G f r/� ��11�GdZdress � Installer Address UType of Building Size Lod!.,-',o___f�� .......Sq. feet Dwelling—No. of Bedrooms_------------------------------------------_Expansion Attic ( ) Garbage Grinder ( ) Other—TypOth ,- e of Building -------•-------------------- No. of persons----------.................. Showers ( ) — Cafeteria _A__ ( ) ,. yes. l��t- --••-------------------------•-•-•---••-----------------------------------•--•------•-----------------•-----•-------- w Design Flow _____ __gallons per person per day. Total daily flow..........17.Z2_!0_'___________ ___ ___gallons. Septic T nh Llduid eau ic7t gallons Length-_------------ Width-. __--_........... Diameter__ ------------- Depth---------------- Disposal Trench—No. � K idth--------------- otal Length otal leaching area__-•-•-----_-----sq. ft. Seepage Pit No. ��_ i ere _.____... �el.o lei ________________ Total leachingIre- P a t t t sq. it. z Other Distribution box (C/) Dosing tank �-' Percolation Test Results Performed by...... Date a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.--- ---------- t14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__-_-___:=__-_:,____-- 9 .............................................. Description of Soil '4A Sk � � °' 4� . '' U -------------------------------------- -- ----------............................................... 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 Article XI of theSt�te'Sanrtary°Code,z `Tit u ndersigned further agrees not to place the system in er operation until a Certificate"'of Compliance has-been issue by the board of he lth. f ate Application Approved By...... ------------------------------------e_� Date Application Disapproved for the following reasons:-_______---•------•------•------------•------•-•-------------•--•-------_____---•-----------•-------•----------- --•--.._..---•----------------••--•---•---._.__ ............................................................. . /� _.._Date. Permit No.-•---•--.5 <7r•-------•-••-•---•----------••---_.. Issued-- f`L -------7 - ----------- Date T4}} ,�f"COMMONWEALTH OF MASSACHUSETTS 1; ......... BOAR OF HE .LTbf� . ..._................................................................................ 3:• . , Tntifiratr Of T"ItImpliatirr THIS TO CER�TjIFI'?, That the Individual Sewage Disposal System constructe or Repaired ( ) n alley -- ------•••-----•-- has been installed in accordance with the pr 1sisions rticle XI of The State Sanitary de as described in the application for Disposal Works Construction Permit No-_-__-__-__ e_190_______________. dated---- ': "- -... .............. THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1P1�1. UVCT�O d SATISFACTORY. _-^ DATE-----------•---•-•-••-.�"`--------:��_'- ............. ---- Inspector------------ ........... :`/ ----------------...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD';OF vH1EA, TFV :, o ..... Dinplaiittl ork,4 nuntitrurtiLin Prrmit 7di,� ic Permission is eby grante --- -- •--•---•------------------•---------------------••----------•-----------------••--- to Construct ) or Rep ( ) an Individual Sew ge Disposal System at No._._.. �''" - "�'� 1 'l`'� --- - ------------------------------- -____- ---- -�' ..... / /, Street as shown on the application for Disposal Works Construction Permit No'�d_11......___ Dated_f -_ _:�..-- 77 ---•--••--••---•••----•--- --`-- ----__-__~-------------------------------- Board of hh DATE......................----------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - f TOWN OF BARNSTABLE .00Ar101�t S 3 P� c%,�s S (,f��/ SEWAGE # P1LL.�sGE �n�` S ASSESSOR'S ASAP&LOT NSTALLER'S NAME&PHONE NO. ;EP'nC TANK CAPACrr.Y .EACHNG'PACIN.I T: (type) Wit" _ j'/ r'a TWS (size)_ . JUILDERR OR OWNER >IERMITDATLI: : .—.. ....,._._- ,.--CQWLIANCE DATE,: separation DisttU'tQe Between the: ,i daximum Adjusted Groundwater Table to the Bottom of Leaching Facility .. eet 1 Iridate Water Supply Well and Leaching Facilit,j(If ar�y wells exist on site or within 200 feet of leaching facility) ; i �MtWnMfeet ge of Wetland and Leaclting Facility(If a iy�ietlands exist =Cackingfaci'ry� '1'uraished by l tv ! v[ C Y' `C e. o n. D f� � C{ '�� V C� - 1 O � � � � VJ � ' Q i1 � � ' W � � � � � � \ ` - � a J __� ,\fir, ,-•..._ �_- +.'., e &Wj r' TOWN OF'BARNSTABLE L&ATION 41�3 WAN SEWAGE # VILLAGE Ny ti'lS ASSESSOR'S MAP & LOT a-7 f ' /79 INSTALLER'S NAME&PHONE NO. �- y SEPTIC TANK CAPACITY LEACHING FACILITY: (type) prr (size) 0Ufa NO.OF BEDROOMS yy�� BUILDER OR OWNER A VLI M 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 leachingacility) [ Feet Furnished by 'f n sAc�t 1 bn [ tgfd W vo . c 4¢.at = t F ZO fir' ¢ 'L'e-TOM 42 F-t* eG '�Y2ti -:% S a G►.: d-Z�7 C� F'D• \ lrsS, m M)< GG uG u` '� � lvv�t�t' •�1 VA') A+qs yam ,r ti� ,� i �t WILLIAM � ,., 9 No. 19334 0 ' ' •. r tI �`'tD Sux`I� � ••�s�.-.•.:L � � TGP �vD � �-Od.O t t E a~ "Afu 710 F 9 •3 - -- - - t sunSv�� s1 ,vs %av ,tvv=9L.0 : 76 +..•t�.;Z' '�'. _ Taw �• Nt7 ' t S7Lw✓�. r d d s. .i.�,* . S tics r` • S/ rr 3 ' g� LOCATto" �� 4, r SCAMA� ups pA.'T . T . �. c-rtZTt;=* 't"AT T"r=L -swo iw Pt_Ai.t R ERE�GE WWV=-ON GcMApt-Y5 WIT" TWS: StUEt-t► E: � ,ekAr.> SETSACtG vEqutizeAAE -jTS of Tpe -T" 'To w tJ o%:= ' l� `jC.c l� OLZ t RCGISR=-izaD t..At• O sue-vayo+4, THt'e-, V LAt-t I; �loT P�nSGo Uw A�.i oSa�2V%u G- a t4tASS. AP P L I Gh.ttil T" �Q ',: + I► I �� ram.J, , ' YOU WISH TO OPEN A BUSINESS? , For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must.first obtain the necessary signatures on,this fom) at 200 Rlaiii.St., Hyannis. 1st F.I. :3f�7 plain St. Hyannis, M a260 i (Town Hall) and get the Business Certificate that is I� Town Clerk's Office, y Take the completed form tote required by law. DATE: I `Z- - (2- Fill in please: . „ APPLICANT'S YOUR NAME/S: i'Y� CC� I O` �. u` . � BUSINESS YOUR HOME ADDRESS: C C 3 T� N C-_ F1�/ IV �N S �/� �' 80 TELEPHONE # Home Telephone Number C> r NAME OF CORPORATION NAME.OF NEW'BUSINESS -' �''1'L'`: TYPE OF BUSINESS C 1`CGi — IS.THIS A HOME OCCUPATIONS YES O r� f / /-/C ?C t.� A i lka �c 'S MAP/PARCEL^NUMBER ADDRESS OF BUSINESS f, When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This.form,is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street] to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** �. COMMENTS: 2. BOARD OF HEALTH This individual has bee ormed of the permit requirements that pertain to this type of business. Authorized.Signature COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: rig 1 . 4 Date: /2/ 04 / 1 TOWN OF BARNSTABLE ReC=F-1.,i2A t TOXIC AND HAZARDOUS MATERIALS OWSITE . � FW4 NAME OF BUSINESS: 6,2C E N Ui L� i c BUSINESS LOCATION: INVENTORY MAILING ADDRESS: 1, 7 1 11 V/tip` TOTAL AMOUNT- TELEPHONE NUMBER: _ y ,� ?/ C( ( 2� CONTACT PERSON: __/_ L EMERGENCY CONTACT TELEPHONE NUMBER: 2��j_f 3 l �� Ulf. 3 MSDS ON SITE? TYPE OF BUSINESS: 'w c,,-- INFORMATION/RECOMMENDATIONS: j Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. . .' LIST OF TOXIC AND HAZARDOUS MATERIALS ` The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum (� Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED v Cesspool cleaners Automatic transmission fluid Q Disinfectants Engine and radiator flushes 0 Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED Q (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas p Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) j) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink G Degreasers for driveways&garages r Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries p Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents U Leather dyes Car waxes and polishes Fertilizers L Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, ottler acids) Miscellaneous. Flammables Other/products not listed which you feel G Floor&furniture strippers may a toxic or hazardous (please list):- Metal polishes Laundry soil &stain removers U (including bleach) / 7/V, Spot removers&cleaning fluids (dry cleaners) �J Other cleaning solvents Bug and tar removers f, Windshield wash WHITE COPY-HEALTH DEPARTMENT%CANARY COPY-BUSINESS Applicant's Signature Staff's Initials TOWN.OF BARNSTABLE LOCAT ON �c� 3 �n ITe_to Ees w d - SEWAGE # �( a VILLAGE 14YAWAS ASSESSOR'S MAP &LOT Ld �q INSTALLER'S NAME&PHONE NO. C_l_t S TWOS, to J5(- 3W -(cot 37 SEPTIC TANK CAPACITY So 0 LEACHING FAGILTTY: (type) t+i-CAP Ct,riapiq'i-az (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: a - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjustzd Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland:and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t �� '�D f O � - - - - j r _� 73 �` �� - � -�- . �- �-� �� -. ,.� No. 91Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for M_gpaal *r5tem Con5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot IV .. Owner's Name,Address and Tel No. �c`�g' �`�11�� ✓u9r�yq � Assessor's Map/P cel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(A,)� Other Type of Building;rle-4 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. l�/We4t/ jVY Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title a Environment ode and not to place the system in operation until a Certifi- cate of Compliance has been is u y this and of H It Signe Date Application Approved by 6111 Date Application Disapproved or the following reason ,,,je" Permit No. Date Issued N Fee t ed i Entered n computer: V_ THE COMMONWEALTH OF MASSACHUSETTS En Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS pplication for Mi-qpo,5a[ *pztem Construction Permit Application for a Permit to Construct Repair Upgrade Abandon El Complete System El Individual Components Location Address or L t Nlg�_- Owner's Name,Address and I&X Tel. o.t-to 141A Z/1 W7 , Assessor's Map/P C�l Instalre s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(4'� Other Type of Building _A6e_4 No. of Persons Showers Cafeteria( Other Fixtures 44 Design Flow (�_gallons. gallons per day. Calculated daily flow Plan Date Number of sheets Revision Date Title Size of Septic Tank -----Type of S.A.S. J!:�2 Z 3 VY Description of Soil Nature of Repairs or Alterations(Answer when e4 .11_74117- applicable) Date last inspected: Afreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title Environment ode and not to place the system in operation until a Certifi- cate of Compliance has been i; ued-15y-this dard of Healt 7 9 Application Approved by L110 *Date A 1LI -Date 11-geanq Application Disapproved for the following reasonell, L Permit No. r Date Issued ——---————————THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of QCompliance THIS IS TO CERTT ag Disposal System Conttructed Repaired Upgraded Y, On-site S b Abandoned Iv_ at the at pac'-N?"e, sy V,:U mmll h ken constructed in accordance with the provisions of Title 5 and the for Disposal System Cons th ctio.n I dated Permit No.Installer 4- Designer The issuance of this pe/ - sh construed as a guarantee that the sys e will function ff a rnitt ��qbe constru s desi.gn^ed. Date Inspector ——————————---————————---- No. Feezo A -,r THE COMMONWEALTH 00 MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpoal *p!Ae (Construction Permit Permission is hereby anted to Cons• t Repair Upgrade Ab nd System locate r�, 4v��/&L 05AV 0ANUAkS - A and as described in the above Application for Disposal System Construction Permit.The applican t recggnizeshis/her duty to comply with Title 5 and the following local provisions or special conditions. K_� �4, Provided:Constriction mum be completed within three years of the date of this permit. 4. AILI Date: h47� q I Approved by /I /AI 1:n 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, Cr-A 0=4 hereby certify that the application for disposal works construction permit signed by me dated 2 Z ,f , concerning the property located at eeo 'C'A 4--1 U/ 1� 7,4-Wlkc rleets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, T / Please :complete the following: g 4? A) Top of Ground Surface Elevation(using GIS information) 0 i B) G.W.Elevation +the MAX.High G.W. Adjustment. e = o DIFFERENCE BETWEEN A and B ` O Bloop � SIGNED : DATE: / [Sketch proposed plan of system on back]. q:health folder:cert 9 l- Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 653 Pitchers Way Property Address i G Countrywide Owner Owner's Name information is Hyannis MA 02601 8-5-08 required for y every page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. - A. General Information 1. Inspector: Shawn Mcelroy a Name of Inspector Upper Cape Septic Services 1 Company Name I G7 29 Atwater DrrLD -- -r Company Address �' ; E. Falmouth MA 02536 ?? City/Town State Zip Code—'— V 1-508-495 0905 S13971 Telephone Number License Number 1 r-1 B. Certification - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR.15.000).The system: ® Passes ❑ Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority T 8-8-08 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 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 r• 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. System operating at about 75% capacity. t5insp•03l08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Y } r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 653 Pitchers Way a' ' Property Address Countrywide Owner Owner's Name information is required for Hyannis. MA 02601 8-5-08 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: System is in good working order and operating at about 75% capacity. , 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: 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 t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 F ,1 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town, State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1 Y . J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.):, ❑ The system has a septic tank and SAS and the SAS is less.than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than'5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ' D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El 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 f E] [ Liquid depth in;cesspool is less.than 6"below invert or available volume is less than Y day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ' ❑ . ® 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 CM 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 , ' ❑ ,❑ r the system is within 400 feet of a surface drinking water supply F ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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. J t5insp-03/08 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No i ❑ ® 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? 4 ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑, Were all system components, excluding the SAS, located on site? l 4 . ® ❑ 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 maintenance of subsurface sewage disposal systems? proper 9 P Y The size and location of the Soil Absorption System (SAS) on the site has been determined based on: [D ❑ 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 ® El approximation of distance is unacceptable) [310 CM 15.302(5)] t5insp•03/08 Tibe 5 Official Inspection Form:Subsurface Sewage Disposal Syslarn-Page 6 of 15 I h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 653 Pitchers Way " Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ' ❑ Yes ® No Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 180/day Sump pump? ❑ Yes ® No Last date of occupancy: 6-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: . Date . Other(describe): t5lnsp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System--Page 7 of 15 r Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 653 Pitchers Way Property Address Countrywide . Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: N/A Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy stem: ® Septic tank, distribution box;soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 653 Pitchers Way Property Address Countrywide Owner Owner's Namer information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Y_ Dimensions: 1500 Gal Sludge depth: 12 Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 6' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12.' How were dimensions determined? Tape t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 ' Commonwealth of Massachusetts Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' wM 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with all baffles installed. Rcommended pumping for solids. Grease Trap (locate on site plan):.. Depth below grade: t 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.): 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): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis L MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. ,• ' ' Pump Chamber(locate on site plan): t Pumps in working order: . ❑ Yes , ❑ No ' Alarms in working order: ❑ Yes ❑ No t5irisp•03/08• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not forVoluntary Assessments 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 6-infiltrators ❑ 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.): Infiltrators in good condition. Visual inpection shows infiltrators filled to about 75% capacity. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): t5msp•03108 - .< Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q° 653 Pitchers Way G,M Property Address Countrywide Owner Owner's Name information is Hyannis " MA 02601 8-5-08 required for y _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. aG K O G D i) Q A-. - ! 66 B-,= -33 I' t5insp•03/08 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 653 Pitchers Way Property Address Countrywide Owner Owner's Name information is required for Hyannis MA 02601 8-5-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I Town of Barnstable ��P 7HE Tp . y�P o Regulatory Services BARN9rABLE ; Thomas F. Geiler,Director �$ i6 MASS. `fig °TEa��a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of-,bedrooms approved at a particular property would be 1isted on the "Disposal Works Construction Permit". - If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC ------------ TOWN OF BARNSTABLE LOCATION (Q 5 3 q%-rL V4 EZS ° 1 AJ SEWAGE # 01 VILLAGE 14 J A N iv t S ASSESSOR'S MAP & LOT � INSTALLER'S NAME&PHONE NO. C j— 5 r o5. C'o�:S I- _&l -6a.37 j SEPTIC TANK CAPACITY Sa c LEACHING FACR.I TY: (type) (. t+t-CN e f P1r41904�Z (size) Cj �k �.��(•�'F16" NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: 601 - �cl COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Cxoundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland:and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I ! COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION PARCEL, TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM \ PART A CERTIFICATION Property Address: 653 Pitcher's Way Hyannis, MA 02601 Owner's Name: Marcio De Oliveira Owner's Address: Date of Inspection: November 22, 2004 Name of Inspector: (Please Print) James M. Ford _! Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 026SS-0049 -- CD s � Telephone Number: (SO8)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,-accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November 29, 2004 The system inspector shal)submircopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the .DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes.and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the. for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): t broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 653 Pitcher's Wav Hyannis. MA Owner: tLMarcio De Oliveira Date of Inspection: November 22, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 653 Pitcher's Wav Hyannis. MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 653 Pitcher's Wav Hyannis. MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [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)): 10102-10103: 78,000 gals.: 10103-10104: 122,250 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ----_gpd Basis of design flow(seats/persons/sqft,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: Pumped on 9120102-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1977-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 pal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 TIGHT or HOLDING TANK: None (tank must be pumped'at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 653 Pitcher's Way Hyannis. MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 ga1.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit was dry. The scum line was approximately 4'up from the bottom. There did not appear to be any signs of failure The cover was 32"below Qrade. The bottom to Qrade was 9'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks.or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A � B O a3013 3 O 3 3� yy 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 653 Pitcher's Way Hyannis, MA Owner: Marcio De Oliveira Date of Inspection: November 22, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the pit to grade was 9' Using Barnstable topographic and water contours maps the maps were showing agproxitttately 25'+1-to ground water at this site. Using the Cape Cod Commission technical bulletin, the high ground water adjustment for this site (AIW 230 Zone D 10104)was 5.9'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the system, the inspection andlor this report. 11 f TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY ► NAME OF BUSINESS: ! L L 1 c Snm C_ �J s BUSINESS LOCATION: rz�� Pi �"C14 C r2 S W 4 4 Y n w/,` INVENTORY MAILING ADDRESS: W R ��1- NJVI TOTAL AMOUNT: TELEPHONE NUMBER: O CONTACT PERSON: I-n Jo Jo �3 oe, LCC�12 i o C EMERGENCY CONTACT TELEPHONE NUMBER: 15O R - ? 119 12 3 MSDS ON SITE? TYPE OF BUSINESS: 13 1Z t, C.1 C S't_-�,ti (- LL) ne KS , INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED d Cesspool cleaners Automatic transmission fluid 0 Disinfectants Engine and radiator flushes 10 Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink 0 Degreasers for driveways &garages Wood preservatives (creosote) S Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries 0 Lye or caustic soda Rustproofers 0 Misc. Combustible Car wash detergents Leather dyes 0 Car waxes and polishes Fertilizers Asphalt & roofing tar PCB-s Paints, varnishes, stains, dyes O Other chlorinated hydrocarbons, 0 Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint & varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) u Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): 0 Laundry soil & stain removers f (including bleach) A/ Spot removers & cleaning fluids a (dry cleaners) X Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS COMMONWEALTH OF NIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v a DEPARTMENT OF ENVIRONMENTAL PROTECTION TIT Vr , I , OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSITENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR1NI PART A CERTIFICATION LRECEIVED - �Property Address• 6J YC t'If rS (/t/GeOwner's Name: 5 2003Owner's Address• G' BARNSTABLEDace of Ins H DEPT. Inspection: o Name of InNpector. (please print) rn� o�,j-ri�� MAP 'P Y ame: .�il/!/iO — G flailing Address; o p PARCEL, gs 4 Telephone Number. o� � LOT ; CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system below is true,accurate and c at this address and that the information rt ported omplete as of the time of the inspection. The inspection was performed based on my approved system inspector pursuant to training and e'tperience in the proper function and maintenance of on site sewage disposal systems. I am a D EP �Section 15.3.10 of Title 5(310 CfIR 15.000). The system: � Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: o2 -o2 f-/-p The system inspector shall submit a copy of this Dom)wttlurt 30 days of completing this' �pectton report to the Approving Authority (Board of Health or p g 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 DER The original should be sent to the system owner and copies sent to the buyer. if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at thlt time.This inspection does not address how the svitem Mill perform in the future under the same or dif(crent conditions of use. �I Pjgc 2 of l l OFFICIAL INISPECTION FORINI— NOT FOR VOLUNTAR"Y" ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART A / CERTIFICATION (continued) Property A/ddrM: 6s� /cop LVO Owner: Date of Inspection: Inspection Summary; Check A,B,C,D or E/AL complete all of Section D A_ Sys asses: I have not found any information which indicates 15.303 or in 310 C�� 15. that aav of the failure criteria described in 310 Ci\.1R 304 exist.Any failure criteria not evaluated are indicated below. Comments: I • Sys m Conditionally Passes: repaired Cane or more system components as described in the"Conditional Pass"section need to be replaced or 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 D) n the for the followin ,N,N ig explain. �statements. If"not determined" please 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 e:diltration or tank existing tank is replaced with a complying ��is imminent. System Hill pass inspection if the *A metal septic tank will septic tank as approved by the Board of Health. indicating that the pass. if it is structurally sound,not leaking and if a Certificate of Compliance tank is less than 20 years old is available. ND explain- nervation of sewage backup or break out or hi obstructed pipe(s)or due to a broken,settled or uneven distribgh ution box.SeSTcm will PJSSudon bout due to broken or approval of Board of Health): lzus inspection if t w,� broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than d 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: kY Pagc3ofII OFFICIAL INSPECTION FOR, [ - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART A CERTIFICATION (continued) Property Address. Owner: I G Date of Inspection. C- Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to dete is failing to protect public health safety or the environment rmtne if the szstem 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. Svstem will fail unless the Board of Health any)dete system is functioning in a manner that protects the public health,safety andic Wate Supplier,1environmen�t:Ines that the 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 private water supply well**. Method used to determine distance feet but 50 feet or more from 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 ppat, pro%ided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3• Other. I Paue 4 of l l OFFICL-kL ENSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,,vl PART A CERTIFICATION(continued) Property Address; (0 rf (4,-1 Owner: 01 Date of Inspection; �s D. System Failure Criteria applicable to all systems: You must indicate"yes' or"no" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clo�ged SAS or ol /Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Clogged SAS or cesspool J� Static liquid level in the distribution box above outlet invert due to an overloaded or cesspool clogged SAS or Liquid depth in cesspool is less than 6"below invert or available volume is less than V-day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed piPe(s).Number Of times pumped V y Portion of the SAS,cesspool or privy is below,high mound water elevation. at portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 3�t" y portion of a cesspool or privy is within a Zone 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. --A'y Portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water �PPIy well with no acceptable water quality analvsis. [This system passes if the well water analvsis, Performed at a DEP certified laboratory,for coliform bacteria and volatile oceanic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and aitnte 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.] i v-v (Yes(No)The system fails.I have determined that one or more of the above failure criteria ex described in 310 as ChIR 15.303,therefore the system fails.The system owvter should contact theBoar Health to determine what will be necessary to correct the failure. d of E. Large Systems: To be considered a la g gpd. e system the system must serve a facility with a design flow of 10j)4)4l gpd to 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 drinlang 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 U you have answered"yes" to any question in Section E the sy stem is considered a si nificant threw 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 sy stem in accordance with 3 l0 Cult 15.304. The system owner should contact the appropriate regional 0fFice of the Department. Page 5 of 11 OFFICL-kL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:d �� 1 , C Owner. �� c�s��Nr� Date of Insple ion• Check if the following have been done. You must indicate`bes" or"no"as to each of the followinz: Ye No /Pumping information was provided by the owner,occupant, or Board of Health v Were any of the system components pumped but in the e�i ". pr , ous two weeks -(� the system received normal flows in the previous two week period "ve large volumes of water been introduced to the system recently or as part of this inS'Pectton l� Were as built plans of the system obtained and examined?(Tf th were not available note as N/A) h Was the facility or dwelling i g inspected for signs of sewage Eck up Was the site inspected for signs of break out v Were all system components,excludingthe Ste, located on site Were the septic tank manholes uncovered,opened,and the interior of the tank tns�ec Of the es or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of shun Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no, Existing information.For e..-cimple,a plan at the Board of Health Determined in the field(if any of the failure criteria related to Part C is u issue VPro'umation of distance is unacceptable) [310 CNIR 15.302(3)(b)] Pagc 6 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSLNIENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR;,NI PART C SYSTEM L(FOR;,vLaTION Property AddreIIII IFss: V 7 // l , / Prf W� h Owner. ,�� 6 0/ �L Date of Inspection: — p? RESIDENTLkL FLOW CONDITIONS Number of bedrooms n 310 - DESIGN flow based on 310 Number of bedrooms(actual): Civ 15.2U3 (for example: 110 Number of current residents: gPd x#of bedrooms): 4(L,c[Q Does residence have a garbage Is laundry on a grinder(yes or no): /�Q Laundry ston a a Sete sewage system(yes or no):_0 if Yes separate inspection requiredl Seasonal use: C e Y it ed(yes or no): A/o s or no): [I pf Water meter readings,if available(last 2 years usage Sump pump(,Yes or no):.f° g ( )) Last date of occupancy ,441 CO LVMERCIAIJIND USTRLjLL Type of establishment: Design flow(based on 310 CNIR 15.203): ,,,�. Basis of design flow(seats/persons/sq�e tc.): 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): Pum p�ins Records GENERAL INFORMATION Source Of d Was systemPumpednon: �ti �/�� — /� /019/ If yes,volum P�of the uupection es oc no): _ Reason for P PCd---dons—How was quantity Pumped determined'' Pumping: TYP FF SYSTEM V�`Y"c LInk distribution box, _ soil absorption systemSingle cesspool Overflow cesspool _Privy _ Shared system(yes or no) (if yes,attach previous in _Innovative/Al1emative technology. Attach a copy of inspection records, if any obtained from system owner) P current operation and maintenance contract(to be _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components.date installed(if n7-n) source of ,Von: Were sewage odors detected when arriving at the site(yes or no): Pagc 7 of l t OFFICIAL INSPECTION FORD[—NOT FOR VOLUNTARY ASSESSMENTS SU'BSUR.FACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1NI PART C SYSTEM PI IFORNIATION (continued) Property Address- r 7�C hers Owner: G,, O 6 Q / Date of Inspection: d1 -d�—off BUII.D[NG SEWER(locate on site plan) Depth below gr : Materials of construction:_cw iron — Distance from _other(explain): Commey well or suctioa line: nts(one ondition of joater ints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: /n h Material of construction:_c!/oncrete—metal—fiberglass_polyethylene other(e.'cpLziri) If tank is metal list age:_ Is age confirmed certificate) g by a Certificate of Compliance(yes or no):—(attach a copy of Dimensions: Sludge depth._Scum �/o S�N Distance from top of sludge to bottom of outlet tee or baffle: �5 e Sm thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto f tlet tee How were dimensions determined: u baffle:Comments on ( pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as laced to outlet invert,evidence of leakage,etc.): a �� N`' �ir�-✓ Ctv GREASE Tom: LL/(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: from Distance 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. as related to outlet invert,evidence of leakage,etc.): squid levels f Page s of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR��1 PART C SYSTEM LYFORILIATION(continued) Property Address: rT� f c�1 1 l✓�� Owner. .ql / �>6pj Date of Inspeaioo. ot3 TIGHT or HOLDING TANK.&(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of co nstiucuan_ concrete metal fiberglass_polyethylene other(e'cplain): Dimensions: Capacity: Design Flow: gallons Alarm present(Yes v gsllons/day or no): Alarm level: Alarm in working order(yes or no): Date of last p pum i;ig: — Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOY: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert YlOvwt c+ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to or out of :c,etc,): it Sol�cJ/ tick L -G PU"NEP CH uN BER: (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 appuncnarl etc.y Pagc9ofII OFFICIAL LNSPECTION FORNI— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORNI PART C SYSTEM LYFORNLkTION(continued) Property Address• r— � / J 7`c 4(&"rS Owner. 4, Date of Inspon SOU.ABSORPTION SYSTE- (SAS): (locate on site plan,excavation not required) If SAS not located e,cplain whv: Type co leaching Pits,number_ leaching chambers, number f leachingh� gailenes,number. leaching trenches,number,length: l✓ jC p? leaching fields,number,dimensions: overflow Cesspool, number innovativelaiterttative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of ve- etc.): �etation, CESSPOOLS:,L(Cesspool must be pumped as part of insPection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet im,ert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Ntaterials 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.): PR.Iv'=L=(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): I Pagc 10 of l l OFF1CLkL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINI PART C SYSTEM INFORMATION (continued) Property Address: ��j �� he✓s. Owner. Date of Inspection• SKETCH OF SEWAGE DISPOSAL SYSTEIi Provide a sketch of the sewage disposal system including ties to at least benchmarks.Locate all wells within 100 feet.Locate where pu two permanent reference landmarks or blic water supply eaters the building. 1f6 j r J � zfa ,-� Pagc 11 of 11 OFFICIAL INSPECTION FORM— N r NOT FOR VOLUNTARY ASSE SUBS SSl�1EN SUBSURFACE TS SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM LNFORiIATION(continued) Property Address: Owner. Date of Inspection: SITE EXA,NI Slope Surface water Check cellar Shallow wells Estimated depth to ground water oZ(9 t Please indicate(check)all methods used to determine the high Vound water elevation: Obtained from system design plans on record-If checked.date of design plan reviewed: served site(abetting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ k,--7 Checked with local excitors,installers-(attach docvtne�S Accessed USGS database.explain.. ntation) You must descibeh�w you established the high ground water elevation. / 6'4.1 �a c✓ w o j o F To of / j rt _.\ �r .T '1��^ .•�;S K• r*nT •'9k'. T o ,^�.. �� r.r- rr-; � f �lCj �DL40 wC- tC- a �� FORM30 C,W HOBBS&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I�t/v► S(v_to Ili- CITY/TOWN a DEPARTMENT WJ ADDRESS _ q(9 ! q ^M TELEPHONE � /-, I Address S-(9 -3 �� U" + Occupant_.P, 4q;&4,,, S dZ✓G�Q� Floor Apartment fro._ No.of Occupants No. of Habitable Rooms No.Sleeping Rooms f No. dwelling or rooming units / No.Stories Z- Name and address of owner /yl o�;c� o S, vO� -7 S,7 f Z-- Remarks Reg. Via YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: a-- f" &L*d k aS i-vka.%, Roof c." GCS Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: (n✓-G ❑ MS ❑ ST ❑ P Waste Line: " H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP:_ Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1)- Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Su .Ten.,G 0), Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink ✓ 3S p� Stove tM v �i L t4 6cort,,L4-S 1G1� Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY INSPECTOR TITLE A S DATE -r-1 no TIME 7: � P•M• A.M. THE NEXT SCHEDULED REINSPECTION P.M. w..,. �u-. .. � .... ,_ ._,_ ;..:._ „�..,w-.,, .. ....,- -,. ,rw'rw^�-rt�A.•i?aG;l+t<,33,j?!e"'> y .. .. ?.r.,.� u.. ,.. �:. .. _.�� f � 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in noway be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so.as to.expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5)• Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health.