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HomeMy WebLinkAbout0661 PITCHER'S WAY - Health S 1- Pitcher's Way Hyannis '"PR q 271- 178 f Date: Z / l /lu TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAMEOFBUSINESS: ^L UlE7 Pnl �1V1M&' C04v�' t'Tnv/t BUSINESS LOCATION: it C- (en,S WA 'O L S 641 012 INVENTORY MAILING ADDRESS: PQ P4X 7ZS-2- fi�V�i1v n/i S PA0- 02 6-a 1 TOTAL AMOUNT: TELEPHONE NUMBER: 1 L � 36 1 2 96 CONTACT PERSON: AAMYL"iw �0244X&ram EMERGENCY CONTACT TELEPHONE NUMBER: �bg MSDS ON SITE? TYPEOFBUSINESS: C4rPe.n/tLqi ��— 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 Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes 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 prod ucts:.grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) 221 G, Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, 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) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No. 2003 6"� r ,y' / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MA SACHUSETTS Application for Migoota[ *pztem Construction Permit Application for a Permit to Construct( )Repair(Z)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address Lot No. Owner's N e,Address and Tel.No. ijG,lc25 �Y arv�� ty/�/,q .✓ � aF .�, Assessor's Map arcel / .2 9 n � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5 6 � -2 7 -362 -3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 527 gallons. Plan Date / d Number of sheets Revision Date Title Size of Septic Tank&,61—/a 6 y Type of S.A.S. Description of Soil Nature of Repairs or ltera ' ns(Answer when applicable) Ig Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu y this Board of lth. Signed Date Application Approved by Date Z- 20 G Application Disapproved for the following reasons Permit No. Z©p 73 Date Issued 2 20 0 3 �* ..,No 2flo3-6'73 ` ,+ s `�^ '—K Fee ...JC,/ Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes y'' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MA SACHUSETTS ZippIication for Miopo.5aY *p�;tem Con5truction Permit Application for a Permit to Construct( )Repair(v")Upgrade)Abandon( ) ❑Complete System ❑Individual Components Location Address�jLot No. ',/ ✓'�`y d Owner's Name,Address and Tel.No. C t�/ f'ilG��QS K/�% � /�,A .� o� rti E/Z Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S' o1� '� S i_36 2 -7 i i -5-7 �' o a2 .3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder 0/� Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 gallons per day. Calculated daily flow;2,.3 .- S gallons. Plan Date Number of sheets Revision Date Title t Size of Septic Tank--imr l a G � Type 6PS�A�S� Description of Soil Nature of Repairs or Alterations(Answer when applicable) /-9 �? Sod �� �5 2S v` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued-by this Board of Health.i� Signed f Date ]� Application Approved by Date Z 20 G3 Application Disapproved for the following reasons Permit No. Z 6 o 3.-o 73 Date Issued 2- 2 0 3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by /9 2 e' v 65- — S5 �d at &/'G / /i L,{ , `I .r h.19 ;has been constructe int446C cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Zoo 3-0 73 dated 2 2 U 3 Installer Designer The issuance of this pe 1t shall not be construed as a guarantee that the systems ill t' 4 as es' ned. Date 63 Inspector r No. 2 VO 3- t)`j3 -_ ---_ __ -__ - ---. _-- _ __-�_..-- -- -- -- ----•-- --.�_._�. - FeeTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS =igpo.5al *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( ) System located at -T.�'"'/ r 2 .S- GCSE % �' -�'- -+�K-'s and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con 7703 ion Est be completed within three years of the date of this pe it. Date:_ 2 U Approved by /TOWN OF BARNSTABLE LOCATION �i r"�/1 c�S��91✓ SEWAGE # ���—D` 3 ASSESSOR'S MAP & LOT 2 I- 8 VILLAGE `�Y INSTALLER'S NAME:&PHONE NO.� SEPTIC TANK CAPACITY f�Je" 7' LEACHING FACILITY: (type9-°�J SDI��0 2 S (size)02 x 3 X NO. OF BEDROOMS 3 BUILDER OR OWNER 20 (j COMPLIANCE DATE: 24 03 PERMIT DATE: l 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by F �D 34 f3�=az S TOWN OF BARNSTABLE LbtAT.ION Tc,�c 2s-,yh SEWAGE # ®()'3—0'73 VILLAGE 171YA ASSESSOR'S MAP & LOT-2-21-178 INSTALLER'S NAME&PHONE NO.A 2 eoeY(a'�V-5, 6—d7 SEPTIC TANK CAPACITY ;il i S 7- LEACHING FACIL=: (type 2) Sdo( ;011,61�1t 2 S (size)d--<-X/3 X' NO. OF BEDROOMS 3 BUILDER OR OWNER LQ- PERMITDATE: w U COMPLIANCE DATE: Z D-3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a . x , h n m !r n i ` �i ) 71 Commonwealth of Massachusetts JIj a Executive of Environmental Affairs 0 1, c DEPr: Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 661 Pitchers Way. Hyannis: Ma. Address of Owner: Frank Pate (if different) 36 Washington Street. Wellesley Hills,Ma 02181 Date of Inspection: 07/27/96 Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - Mashpee Ma 02649. Tel : (508) 4771420 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 inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system Passes -- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s S igna re: Date: 07129196 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 661 Pitchers Way. Hyannis Ma. Owners : Frank Pate Date of Inspection: 07/27/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: KI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below Bj SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determinate CY,N, or ND). Describe basis of determination in all instances. If"not determinated",explain why not. -- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration ,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ..... broken pipe(s) are replaced ..... obstruction is removed ---- distribution box is levelled or replaced ---- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ----• broken pipe(s)are replaced ---- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 661 Pitchers Way. Hyannis Ma. Owner : Frank Pate Date of Inspection : 07/27/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cot- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 661 Pitchers flay. Hyannis, Ma Owner: Frank Pate Date of Inspection: 07/27/96 D) SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. -- Required pumping more than 4 times in the last year NO T due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy, is within a Zone I of a public well. --- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. /Z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) a Property Address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of Inspection : 07/27/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: --- 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. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 914 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of Inspection: 07/27/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the S oil Absorption System, have been located on the site. --x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid,depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods - -x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of Inspection: 07/27/96 RESIDENTIAL: Design flow: -30 gallons Number of bedrooms :6� Number of current residents: o Garbage grinder(yes or no) : f 3C) Laundry connected to system(yes or no): v�S Seasonal use (yes or no): NU Water meter readings,if available: r) A, Last date of occupancy : tq( S COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gallons/day 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 : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sourd of information: "^...!^................... ..... j......... System pumped as part of inspection (yes or no) :... ........ if yes,volume pomped : .................... gallons Reasonfor pumping :........................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 661 Pitchers Way. Hyannis, M a. Owner: Frank Pate Date of inspection: 07/27/96 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) XOther [explain).. ic...' r.. ... .....�.�. ...Q� -................. P-RO IMATE AGE of all components, date installed(if known) and source of information . ................................................................................. ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).... SEPTIC TANK : ..1�� �.. (locate on site plan) u Depth below grade: ..�V.... Material of construction: ....X.. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: Sludge depth:...3''....... Distance from top of sludge to bottom of outlet tee or baffle:.... ..................... Scum thickness :.a.".............. Distance from top of scum to top of outlet tee or baffle: ........L fl). ........................ Distance from bottom of scum to bottom of outlet tee or baffle :....4.1.............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidences of leak�e�etc.)...................... L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PAR T C SYSTEM INFORMATION (continued) Property Address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of inspection: 07/27/96 . GREASE TRAP : ...... ..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:.............. Scum thickness:..... Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.)........................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:.....U.6.. (locate on site plan) Depth below grade:.:............. Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches, etc.) I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i Property Address: 661 Pitchers Way. Hyannis Ma. Owner: Frank Pate Date of inspection: 07/27/96 DISTRIBUTION BOX..00. (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into orout of box, etc.).................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ PUMP CHAMBER:...... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.).................... SOIL ABSORPTION SYSTEM (SAS):.. CS......... (locate on site plan,if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ Type: ..:............................................................ . ............................ .................................. leaching pits, number: ...�..�. leaching chambers,number:........ leaching galleries,number:........... leaching trenches,number ,length:..................... leaching fields, number, dimensions:................... overflow cesspool, number:.......... Comments: (Hoke condition of,soil , si ns of hydraulic f ilure, level of pondin , condition of v gelation, c.).. .. 1...,t s. o. .t. .... V.f1?�.... . .�. . t� N , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of inspection: 07/27/96 ,,,, 11 CE S S POO LS:..Iv.0.... (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY : ........ (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ � l LO,CATI SEWAGE PERMIT NO. off' /� 7 37 ✓77 VILLAGEP-t-Zile,� 1NSTA LLER'S NA & ADDRE S B U I-L DE B 0R IYWNER DATE PERMIT ISSUED :22 DATE COMPLIANCE ISSUED � �_ 7- '� � xi �� �� . , No.•-- 31__........ tom,a! Fizu... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE T --------OF... .... .................... ... .... . ........... ............................ Appliratinn -fur M-4poiitt1 Workii C otuitrurtion Vantit - Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sew ae isposal System t: ---�_.... .. ---�---- ------- ------•- . . r_ Locat Address e or Lot No. ----------------------------------- Q v / %Xner d es Installer Address d Type of Building Size Lot--.---- ----� Y.. Sq. feet U Dwelling—No. of Bedrooms..______3................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __-_ ...a. ----------------------------- W Design Flow........s_. gallons per pet-son per day. Total daily flow__._._____.__ ___-_____-. gallons. -------------------•--g" P P P y y WSeptic Tank—Liquid capacit/01:O-4 lions Length................ Width................ Diameter---------------- Depth._.._--_------- x Disposal Trench—No. .................... th.....................T Length.............._. .. To, leaching area---------------- ---sq. ft. Seepage Pit No.-. .. `� .-----•-......_ o in :.................. leaching area-------.----------sq. ft. z Other Distribution box ( Dosing tank ( ) ,dA. 906 431-- 'z-` /-•/.--7 7- aPercolation Test Results Performed by--------------------------------------------------------------------------- Date.................................. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------....... G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a ---- --------------------- --------------------- -- Description of Soil--------d-b.........W .- •--------•------- --------d � -- - - - -7•- F--- __�C =I, --- ----- - ...............................-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- . 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 the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of health g �� 77 Da e Application Approved By--.'.'., -----'' .`_ ....... ------- Date Application Disapproved for the following reasons:--•------------------------------------•-------•------••------------------------•-----------------.......-•----. --•-•---.....--••--•--....----•-•----...-----•---•-•-•-•-•----------•--•-------•-------•-•----••-------•--•--....-•-•-•.............••-•---•---•---....-•-----------------•--•--•-----------------.----- '-ry ..Date Permit No......................................................... Issued---- ....... F J �. 0 .�.. No.....3 7..---•---- r Flz>s.............................. THE COMMONWEALTH OF MASSACHUSETTS '77 BOARD OF HE��r T .._OF... r � .i •rG .... ......1.... � -.......................... Appliration -for Di-lip ial Workii Cnonsirttrtion Prrutit Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at Address.. 3 --- - /� r Lot No ��' 2 . W �� � =wner �� � �--•y'�dd ess� ......................----•^....................................................... Installer, Address I d Type of Building (/ Size Lot----_..�. �-.Y.`%!.-s.Sq. feet U Dwelling—No. of Bedro ------------------------------------- Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ---------------------------- No. of persons._---_-_----_---.-.-__---- Showers ( ) — Cafeteria ( ) GW Other fixtures -2..--------•------------- -- �.__ W Design Flow........ __0__________________________gallons per person per day. Total daily flow------------ _ .................gallons. 1:4 Septic Tank—Liquid capacit/ llons Length---------------- Width---------------- Diameter_----..._...___ Depth.--------------- xDisposal Trench—No- ____________________ ` idth___._______.____....T ;fal-Length-------__--_---_ .. To 1 leaching area--------------------sq. ft. Seepage Pit No.._1 =1' �D iet�e -1 �______iDep eYo` in of '............. lea king area_-_.___.__.-•__sq. ft. Z Other Distribution box ( )/� Dosing tank ( ) oh. /c� - L, /`/- 7• aPercolation Test .Results Performed by--------------------- -------------------------------------------•---•---- Date------------------------------------ .. Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..._---..-.______-._.... fX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_.__--...__._---.._. P4 --...._.. ----------- -•-•---------------- -••---------•-----•---- Description of Soil. �L-------- �`pcm_a_._�e..--: `� G'� .. . a ? L� � `�r�+,r. = - ' i -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard f healtt S'gned a�11 -A''./%✓' 1�-`/ •----3- Application / - 7 7... A/� �� Date Approved By------f►✓ G�4,4 --�- .7 7 Date Application Disapproved for the following reasons:-------� ____________________________________ ......--•---...•-----....-•--•-•--•--------------•---•-----------•---....-•------------------------•----------------------•-----.---••----------------------------------------•-----------------.----- Date PermitNo...........................................-'•... ........ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS — � BOARD,, F HEALTH �i`-`'z. .......O F.1!..: :....... ...................................... Wrrtif irate of Tramp aurr THWS TO CERTIFY, That t e Individual Sewage Disposal System constructed <or Repaired ( ) ---- frl ^• f/ Installer / ---••• at ......->--------•------•-•--_---- �' fl?��!° f'• ��L--at ~ has been installed in accordance with the provisions✓of art' m y€ he State Sanitary Code as described in the application for Disposal Works Construction Permit No._ _�?__ ----------------- dated.... -__7._7 ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD CIF HEALTA 7 3 ............. ✓f!f�f/ 'C -...OF// ,�'/ Uy""" ...�........_..:.:f..................... 5� No.-----•...- --...... FEE. UisVoiittl ork,q Qlan,itr�uryi t Prrmit Permission is he eb' g ranted------ --------��/'G." 1 7 ---- --------------------------------------------------------------- to Constructer , or Repair,(, ) an Individual Sewage Disposal System! at No -- - ---------- ------ - --------------- },�.�.,.---- �-- P .-C�� z„ ,/f Street` ._....._ as shown on the application for Disposal Works Construction Permit No. ____.--____ Dated... ..l_-_�-7 7 ------------------------------------------------------------------------------------------------------ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS x i - i 5 =` Its 1 �lOao GAc: 160o GAI. .. ,n fi o � i -c3 �Z7. G 7' ' \Yl"• Z G 7M i f, A •i4 9AXTE H 1 ,� F``� <-j�, - ---'ti1 LyCAT1U'r�i � yA nt rJ� s, f"if'•s�,,, SCSAL.C= Fc 30 ` 'D /7-7 i CeiZTiP T�4AT- T14i— FOUNPATtON 5Wov)►.l -�E>2cc�J �fL�n.k%-'L--rs wt T" TI-IE-. 5lVEU .Ji--- LnT3 SETBAC4 FGQUt+ZCAtc►..tT'S vt= Tt-►c PLA tti V. . 30 -PG. J � -Tav,/ 1 Uh 6ARN-57Ale,L.E PA.-rc z/`25/77 Lc n . 1:..) B/S,7CTCiZ ;t, 1,1YL 1iJG. t2EGlS r1=iZLD i.J "Co SUZva`fozs TWIS QL-A -.t iS L407% 135"e'O O t-,Ur t3i= USC-o Tv DETirQM04& LG'T LlWeS G "2"PE O. IO,CATIOW P NEWAGE PERMIT N0. 4/0 VILLAGE 1NSTA LLER'S Nk E & RDRESS zz- BUILDER 0R`� OWNE DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r i.7�' No........... ..•...../-� ...... +' Fa$...r` .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF t HEA TH/�� - ApplirFation -for Bitipos a1 Workg Tomitrurtion Vamit Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst at _ .......... ......... 'L.... ............ A.. ......................................................................... ocation-Addfess or Lot v er Addr a -------------y�---------------------------- Installer�/�i/ Address Type of Building ��// Size Lot-.,� - a_ Sq. feet Dwelling—No. of Bedrooms.------- -------------------------------Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p' Other fixtures W Design Flow-----;:':�.............................gallons per person per day. Total daily flow...........3ja_q_________..._-._-.gallons. WSeptic Tank—Liquid capacityAWOO alions Length................ Width--------.------- Diameter-----.---------- Deptli_.._____-__.... x Disposal Trench—No. ................... Width-----------------c 1 Length----- ._.___. Total leaching area--------------------sq. ft. Seepage Pit No.___yfe-©f/___ ____________________ o p, __ otal leaching area__34_ '___sq. ft. z Other Distribution box ( Dosing tank ( ) D,�O �C 2— /'/-. 77 aPercolation Test Results Performed by------- -----------------•--------...•-••••--••-----•-----------•---•-•-•• Date--_------------------------------------ ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit____________________ Depth to ground water.._.____-___.-_-_-_.---. �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water........................ f - - a �---•- f/' ...escrpton .. -- ------- •----- - ------•------••---•--------------- � l---------------- --X-----� ---- - ----- 1 � --------------------------------------------------------------- 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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bq.rd of ealth. ign --••--•• r --• ......='.%--.... . -- 3 -- ----�� 7 Dat� Application Approved By. --••••--• •• ....................... ------u- ' Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- Date Permit No......................................................... Issued.. ...� � Date --------------------------------------------------- 77 --- D .� No.. ............. THE COMMONWEALTH OF MASSACHUSETTS r- BOARD QF HEA T _7 . ... _'fit...._.. .OF _/'.... =- its✓ - -- ............................... Applirtttintt -for Uiipm5ttl Works Cnomstrurtiott Vrrutit Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at,,; j ......................../ f ............................ ....-rr Location-Address � ! or Lot No. Owner .............. Installe Address Type of Building Size Lot.../ J------.--Sq. feet Dwelling—No. of Bedrooms--.--.-- 3--•---_---------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures,!:z<•!r---..-r< -- ------------------------------------- W Design Flow.---.-'_� ..............)--------------gallons per person per day. Total daily flow----------30_5. ...................gallons. 9 Septic Tauk—Liquid capacity-O�Vgallons Length---------------- Width_.............. Diameter----__-..-_-- Depth.._.-.-_-_--- x Disposal Trench—No- ----..--..�._..._ Width-------------------z-Total Length----------- ------- Total leaching area--------------------sq. ft. Seepage Pit No......f'/r C ���? terms ----------_'%Dep h�b�l'o� ------CIA It. z Other Distribution box ( �) Dosing tank ( ) oh CIA - ?- `�' 7 7 aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------..-.----_.--------._----.--._-. Test Pit No. i................minutes per inch Depth of Test Pit-.------------------ Depth to ground water---._._-_----_--..-___. (3:j Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.--..-__----.---. - Ix --.._---- ---------- -- Description Soil---. - . � -----.--- -f �---- rrr. c � -------------•-------------------- x - p- �%2 f1� f �i U --•---------- --� r x M. ------------------------��- ... ,1 - -- -- -- -------- 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. g !� v Date Application Approved BY �'� =-------------------•- ----3- ".. 7 ------ Date Application Disapproved for the following reasons:-------------------------------------------.-•.-......-•------------------------------------------------------- ---•--•-•---•------------------------------------•--••--.- Date PermitNo__.................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARDD F HEALTH__ .... t% .1 'zt-......0F.�!�..._. 1 /?. i �--..i..Z ....... .................... Q,rdifirtttr of Tantphattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed _ or Repaired ( ) b . ...LP-------r ' e - - ----------- •�- _ Installer at.. '�`�1 j= I f �r..-•- `tiv�1',�' /ice ....................................................... has been installed in accordance with the provision�of : ticle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. �_...._. ................ dated....:-l_--7.7-.....---_-........ THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................--------...................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS � �: •�-----7 BOARD O F HEAL- ......... > 7. '`' r �i�J ;.......OF.. // .�vtai - ......... No......... --••••• .Fjr FEE........................ �i��tt�ttl ttrk,� �� �tr. •rti�tt �rrtttit Permissionis her by-granted-------(L-.ta.lay-/_- -------- - -----------------------------------------------------------------------•......----•-••---••---•....••- to Construct or Repair ( ) an ndiv'duaI S ewage Disposal System at No.... `7 �� ..k:?------.1,c-I ..... 1 treet as shown on the application for Disposal Works Construction r.iit o._- ._f.-. . .---- Dated-..,7. ------------ ----------........... L '' ..--------------•------------- 3---�--f.c� Bo aid of Heal h DATE...... 7........--------------------------•-•-......•--•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS , r N � It # rn e VI t ,�) Pi'► c 1 000 O TAN It h exP b 0 V � o OF Ik F ' 1 � , F E r� H Y ,N N 15 j"�A, �. Fa U N DATloNF>t 1c:,c,1.J s-r 'P L A4. Z_ �• y . ,fir, 1 i t r t_�`� .:,i' � i __ L, r c E_ Vl/ REV C 0 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 661 Pitchers Way. Hyannis, Ma. Owner: Frank Pate Date of inspection: 07/27/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. t A V 2 0 :6 DEPTH TO GROUNDWATER: Depth to groundwater: ..feet Method of determination or approximative: ........................................................................................ ................................................................................................................................................. ................................................................................................................................................ COMMONWEALTH OF MASSACHUS4r LED INSPECTION EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION z W T m [RECEIVED V 2 7 7002 5 . ..EALTH, — TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �® � CERTIFICATION 1 Property Address: 661 PITCHERS WAY HYANNIS, MA 02601 MAP Owner's Name: LILLIAN BOEMER PARCEL Owner's Address: 661 PITCHERS WAY HYANNIS, MA 02601 LOT � 'I Date of Inspection: 11/19/02 Name of Inspector: (please print) JOHN GRACI 14, COPY Company Name: SEPTIC INSPECTIONS h1C Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally PP es _ Needs Furthep.l7valuation by the Local Approving Authority X Fails Inspector's Signature: a Date: 11/19/02 The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect' n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS UP TO PIPE. SAS NEEDS TO BE UPGRADED. ****This report only describes conditions at the time of lusperllou tultl tllttiel. Ilse contlillou,v of 11se ill Iloil Ilow. 1 11h inspection does not address how the system will perform in the fntnrr under Ihr same or tlilTrrrnl rontlitions of nslu, r Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 661 PITCHERS WAY HYANNIS, MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 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 FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS UP TO PIPE. SAS NEEDS TO BE UPGRADED. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 661 PITCHERS WAY HYANNIS, MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of am-monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) X _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered ")'es" in Seclion D above the l,1rge sywiii him f�lletl: The ownl ,r or operator of any Jai Fe system considered a significant threat under Section E or failed under Section I)ShallnhNru�lc the yyyl�+In in na-nlrilnlh'r' %VIIII 1 III I NV 1111H 'I III! 11y'lloll 1IIYIU'1` should contact the anhropriale ivginmll (►Illo, id'11w 1 li�oll IIIIIqII r Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`' X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum '? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 661 PITCHERS WAY HYANNIS, MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedroors(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 systern(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records , Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 BY 01VNER Were sewage odors detected when arriving at tlrc site(yes or nu); N1) Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 661 PITCHERS WAY HYANNIS, MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 BUILDING SEWER(locate on site plan) Depth below grade: 10" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 4" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" 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: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): NO D-BOX PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LIQUID LEVEL IN LEACH PIT IS FULL UP TO PIPE.SAS NEEDS TO BE UPGRADED. BOTTOM IS AT 7'6". CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A �cc� , Mi e A p, AA 2� . A 30 Lj try in ' Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 661 PITCHERS WAY HYANNIS,MA 02601 Owner: LILLIAN BOEMER Date of Inspection: 11/19/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+ FT. �$ ASSESSORS MAP: 27( NOTES: TEST HOLE LOGS PARCEL : ( / 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR: o A,t mcagep- HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: G 1 /.� _L�. WITNESS : hI A1�21� I-I= BOARD OF HEALTH REGULATIONS. REFERENCE: 31o� DATE: J prou ' 3 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, S PERCOLATION� RA E:_ SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO Pd INSTALLATION. SITE L '"""�� ►� TH- 1 El 51 ,90 TH 2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION 0 SDI ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION. Lo 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS SPECIFIED OTHERWISE) LOCAT i ON MAP ( •T.S.) �-51� N S) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) R MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON st y7 tip A BASE OF 6"OF CRUSHED STONE. ?-15Y 14 7), gn p A&o CA64ei) 53 53 �ln ttruawr� w , t�S WII l5D of (} joa, c 6 Cat a4liV AAIP E WCU. w.J /vr� 0� � SEPTIC SYSTEM DESIGN 9�.L� � -----�.�-�-- � -� �'t► �� �� ►57In1tf /OJ �! _��Af 71 FLOW ESTIMATE b0 U��_.f? r11� '' f(! o-NS /tE /1 BEDROOMS AT 116 GAL/DAY/BEDROOM -33a GAL/DAY SEPT I Cf TANK y 330 GAL/DAY x 2 DAYS - GAL USE )090 GALLON SEPTIC TANK -e_ tS? - I?rPL. w .. SOIL ABSORPTION SYSTEM uNve2s►�„�p C�}-s T tae.Ar_ F- H,9wtB ,S S7vt✓ m (.S/h&S- 25 L x 1-5 v�1><2 S1 ^ N� I SIDE A�tEA• � ZS)��� ,?Z��.z. 42-7 a- �Av T BOTTOM AREA: Zs- X �3 — x O,7 N 24y Sa f 52 SEPTIC SYSTEM SECTION WA i y 1roF=•S ,t� No �P 2 I�u OX 21ia GAL �19,f 3 ;�I L�7. SEPTIC TANK fiV low U 1 Elrlk-) ASH OF iyq 17Z,41 OC �U DAR En-, SITE AND SEWAGE PLAN o. 1140 �`��►sTER``° FnfION : 6(o l PI7-eAteS U4ff T SgNITAR\PN PREPARED FOR : C6L '- 0 3� ® to L ►'u,!Q I ,�-. SCALE: �'� a � DARREN M. MEYER, R.S. � ►1 I i ', FL&IJ Or' �A'N f� , l ey `• r3�5 - DATE: 1 0 43 VINE STREET DUXBURY, MA 02332 W ( -IQ 7 DATE HEALTH AGENT 781 585-0293 i