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1115 PITCHER'S WAY - Health
1-115 Pitchers Way Hyannis A=273-203 i TOWN OF BARNSTABLE 99 LOCATION 0 1 S" P 0KVA/-S ` C-y SEWAGE# 0? 10 VILLAGE�`�, i S ASSESSOR'S MAP&PARCELS'; O 3 INSTALLER'S NAME&PHONE NO. Sco VdAe!b(o ar, �V SEPTIC TANK CAPACITY cs 0 K 0.L H of b p Q O X LEACHING FACILITY.(type) Sti0 �C,\\d n Nk%® (size) y 3 X oa NO.OF BEDROOMS OWNER G3e s PERMIT DATE: 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 leachm facili ' g+ ha.,��..;, { .,... � Feet FURNISHED BY n " IZI n CO t.� s .t .c (A) )A) w i° X p J UT W L4 C .. 6� A F TOWN OF BARNSTABLE LOCATION ( 1 I S 2 SEWAGE # VILLAGE AS SSOR'S M�& LOTS®� INSTALLER'S NAME&P NE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .(size) NO. OF BEDROOMS BUILDER OR OWNER -C 'C16✓� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by S. Q "fir' ell v2D - k-v `+ No. 6 f Fee Ile) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RppliLation for Disposal *pstrm Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade(V) Abandon( ) ❑Complete System 21"nodividual Components Location Address or Lot No. 4\ \ v Owner's Name,Address,an Tel.No. Assessor's Map/Parcel 913—a N C,nn\S Installer's Nane Address and Tel.No. Designer's Name,Address,and Tel.No. Cti�l to 33 Sccs�} shrvh V'� 3 v1,J XW c^�.c . 2J �� J G d c,y b•a v�.s o x(em a o Gt aJ k� w� Type`h Building: may` Dwelling No.of Bedrooms Lot Size /J u sq.ft. Garbage Grinder(AfP Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 30, 5 gpd Plan Date S l 1 Number of sheets Revision Date Title Size of Septic Tank e O 1 Type of S.A.S. D C GtM 6 trs Description of Soil .a/'1 S \A a 6 Nature of Repairs or Alterations(Answer when applicable) A"i AQs:Nye qX A\r c n ,L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date a I Application Approved by Date — 2 Application Disapproved by Date for the following reasons Permit No. ,Z 0 9-1 p & Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y C% PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippliiatlon for MispoSal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. `� �,\ C� -r S \J* f Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Addressand,Tel CS�� X�t � R Designer's Name,Address,and Tel.CNo. e 3 1D0%V%c9 G v ca��a r,c�� u M 0, aXbGl �-oX -a`► 0065 tSS' (s-c 1 fz z�k f 2J � rV��W M `` ` � r Type of Building: Dwelling No.of Bedrooms J Lot Size �� sq.ft. Garbage Grinder(!JP Other Type of Building No.of Persons Showers( ) Cafeteria( ) Y' Other Fixtures Design Flow(min.required) ,�`��� gpd Design flow provided 3 (7� gpd Plan Date 3 f f 1 Number of sheets Revision Date Title // Size,of Septic Tank C k 1 SAC C6�1 t�' Type of S.A.S. (rj\�6() Qj(, ,(6 A A/ 16 Description of Soil T-) C;C6.j-% GJ1 CJ J I. 1 Z. \A p. b �t�x Nature of Repairs or Alterations(Answer when applicable) ` r, A 3 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. (S Signed 4 S'—'C Date j Application Approved by Date 1 " - r Application Disapproved by Date for the following reasons Permit No. ;Z 0 7-1 0 & Date Issued - l i _.. --•--- - - - -- - -- - --- - - - ---------- - - - -- - -- - - --------- THE COMMONWEALTH OF MASSACHUSETTS ^ y BARNSTABLE,MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIF�Yi,that the On-site Sewage Disposal system Constructed( ) Repaired(V� Upgraded( ) Abandoned( )by at (� r- Nm it s-C L> C%�_ if` WNAIt& has been constructed'in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 oa r-0 7G dated `" Installer `lc c- .__Vt_ Designer ( � , , v, ,S C #bedrooms v Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wili`fnnction as desigfte�d. Date 1 . J� Inspector ' �� /�.1� ,ems-' i,�,i _._._ No. a 6 Z/ 6 , Fee [ tJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pStem Construction Permit Permission is hereby granted to Construct( ) Repair(V Upgrade( ) Abandon( ) System located at t 1 J "N t 011—A 0 U)G\.s ,.-fit`�r�ryr• t and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. - ' �z Provided:Construction must be completed within three years of the date of this permit. PP y Date r 1 Approved b t "= Town of3arnstabe x Regujatory$ery e.s Mcba>R~ Y.Scab,Iriterirrr I ireetc r ublic Health b►xvsictn . TEtams.lIicit,Dirt tnr" 204 Main Srcet4 k.ytrrttts,,aVIA a2Qi. C3fti e 50462 4644. Fax: SCI -79.()-61,04 4 ln4alter .Desl ner Certi�icadon form late,' 3/23/21 7 SYvagermrt# Q sessar's .ap11'ar.Ce1273/203 David D C u hanowr RS �Qestgner. 9 9: [nstalter: Y: l C�S c�u;Address 155 Geor9 e R der Rd South Address,• Chatham, MA.Q2633 Qn i S 12 S GU�� Fcr �. ryas iSsuef#a`tret 'tt tt ;t�sstall< (date (�ntle 3 ; septic,systezta<at 1115 Pitchers,UVaY based"c n a des► n"drawn by (address). David D. Coughanowr dated March 5, 2021 _._ clesx ' ei• X i certify that:the septzcsystem referenced above was-atmstall ! sulastantially, cc aording to prove d cijanes`su cl as lat'crat ricat�a n the distribution box aadJor septic tank, Strip out (zi`"rcquired} ryas izispected;and'tlte sd�0 were:found satisfactory.= 1 ccrt fy that the scptic systcni"referenced above wasinstalled with tnajur char is (i.co __ ., seater than l(}' lateral relocation of the SAS oK any"vcrt�cal;-rclocopon of any ca pon6nt oel f the scpttc;systeii but in actor ance:'Noi Statc chi.Local Rcgul'atiians. 1'tan revision or ccrtafierd as-bu�it by: einer:to Billow':; Srnp."out(tf inquired was.inspeetc�l and tic sods ere fci'und satisfactory:', I certify that:the,"system,,referenced aibove was'cohttr e-ted in compliancem.," the terries othl ;aprovalictters(ifappl%cable} ;.' OFF L [ }A ("installer's 3rnature} cp 2 a � �ztlAt�IR (Desigi%cr's:Sgnature"} er's Sta ) LEAST RI TU"l N.Tt A RIV TABLE 'ftt Ut HEAL TjiI DWJSIO : jbERTIEICATE OF CQI LMNCE ,-WILL"=,NG;T RE °ISSUED" UNTIL>'Bt�'I , TIIIS =F R1t� AND UILT<GARD:;A;RE RECEIVED�FiY'THE BARNSTA;BLE;PUB II HEM I,'I II S10,1:1 THANKYOU t$epE�lT c i ner.0 crtiFiaati& iae�n ttcv -1 -i3.rtaci 3 . _, No... .................... THE COMMONWEALTHOF MASSACHUSETTS BOARD OF H EALs VA Appliration for Dislimal Warks Tonstrurtiou Vamit Application is hereby m e for a Pe mit to Construct (� or Repair,( ) an Individual Sewage Disposal system - •- �C.! ....._._. .. j.....Idle ...1.... .g: �. .............................................. Locati - es - or Lot No. �••---•-• ..... ...... - O er Addr s W ` ." �'L.._ .....:.............................. �Z/. ......Install Address e of Build* Size Lot. _,,p; _ _______ �� j � Type i�!N ,� .G ���'r� � ------Sdq. feet aDwelling o. of Bedrooms._...__.7............................. Attic ( ) Gafbage Grinder ( ) pa Other—Type of Building No. of persons____________________________ Showers ( ) — Cafeteria ( ) GaOther fixtures -- ----------------------------------------------------------------------------------•--•------ W Design Flow�._Equid ________________ _.gallo rs per person per day. Total daily flow.• -�� __._._gallons. WSeptic Tank capacity/.� s Length________________ Width___..___________ Diameter____________._.. Depth_______________- Disposal Trenc —No_____________________ Wi th __.___.__.______ o en 9ten h Total leaching area.................... ft. -.--.�---------- Diameter De Seepage Pit No elow inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.................................._--•• ------------•---------•-------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch - Depth of Test P• .................... epth to ground water........................ 0 Description of Soil----- ------------ �� y�" ...............----........................................... x W ------------------------•-•---------------------•---------------------•-----------•--------------------••-•---------••-----------•-•----------•--••---•-----•---•--•------------------------------••••- UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The and ed further agrees not to place the system in operation until a Certificate of Compliance has been * d by th •oar_'o health. Sig d--- - --- ----------------- ---- ---.- -- . ------------ Da.t.e------- ....... ' pp,� / Date_ �11 +� . J �� �f Application Approved BY---=-- -p! - ---- �.. _ .. -•- - --• -:�. ---•--•--•- ��`'G` D Application Disapproved for the following reasons:................................-.............................................................................. ...................................•------------------•---------------------•--•--••-•--.........•---..._.----------.....--•--------------------....---•-••---•----..................................... Date PermitNo......................................................... Issued....................................................... Date .�.••-,..•....._ .. • ... ...................... ...... ........... ........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ......... ...... '�.......0F............ ..' .., ',r�ld ..........................-......... �p ifiratr of Cimplinurr T S IS T0,1,hRTIFY, That e Ind• idual wage 1Voh,,Sp2 , em constructed ( �r Repaired ( ) --- �.... --..:.. by..... •- •- •-- --.---- .-2•...................................•--•-----..............._nstall rat----"'---------- --...:�---- -•---------------•v •---•--- _... .. --------------------........-----•---------•---- has been installed in accordance with the provisions of Article X Sanitary Code s described in the application for Disposal Works Construct*on Permit No________________ - - dated______ ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... ------------------------------ No.. 7.. ... FEE.... ......... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL H ---------...OF....... . ..:...... :... --- .................. Appliration for Uispoiia1Works Toostrurtion Vinmit Application is hereby in MA for a P nut to Construct (**,)'.or Repair ( ) an Individual Sewage Disposal System,, .. ; ...L. x ..... r ma re- ------------•-----•------------------.--- /� oc"a dres dt or Lot No. -- -- --....... O er Address ws..... ..pi(.----- • .............•• ----•--------••-•-•-•--•. nstal Address d Type of Buildu�pp,,� Size Lot_ �_ S�q. feet U Dwelling— No. of Bedrooms:..: " .Expansion Attic .( ) Gage Grinder ( ) --- PL4 Other-Type of Building ............................ No. of persons............................ Showers ( )_ — Cafeteria ( ) a' Other fixtures W Design Flow ------ -... gall s per person per day. Total daily flow . � gallons. WSeptic Tank, Liquid capasity� a s Length................ Width................ Diameter------------------Depth................ x Disposal Trench No. ...... .._.. Width .. o ength ... Total leaching area........... ...sq. ft. Seepage Pit No _. .. Diameter4.D elow'inlet .Total leaching area___ sq.-ft. Z Other Distribution:box ( ) Dosing tank ( `)' 'y aPercolation Test Results Performed by.......................................................................... Date-=....................................... Test Pit No: 1................minutes:per inch ' Depth-of-Test Pit..................._ Depth to ground water........................ Lz, Test Pit No. 2................minutes per inch De th of:Tes P' --------......_..... epth to ground water -._..._...__...._.... ----•-... . ............... . . - •---•--_---- ---•---------------------•--- ODescription of Soil---....-----.------ - = -= ---• •--• - --..• ........................................................... 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 XI of the State"Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i eyd by the oaDo health. a; Sird :..... .......P- 8 Date Application Approved By...... = - *... e f ....... Date Application Disapproved for the following reasons_______________________________ •......................................................................... ...........................•---------•--••-...........--•...__.....--------•---••...........----------...-----------------------------------••--------••------------------------------...•••------------ Date PermitNo......................................................... Issued.............................. .............-------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF......................................... ......................................... (Irtif irair of Tootph4urr THIS IS TO CERTIFY, That e Indi idual "ewage D' sal S-stem constructed ( ) or Repaired ( ) : f"101 -,-_�..(....-•-•---•-•............................................................... Installer has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................:.................---......---._...................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ......................................I...OF..................................................................................... No...............:......... FEE........................ Permission is hereby anted...... •....... s: '. _ ......... '' .... y In ;-y .... .. --- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated-......................................... ..............•-----•-•--••---------------------------------...........---....--...---•-•-•-••----••- J Board of Health YJ / �. DATE..----.s,�:�....... .... .......... .............................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �s i TOWN OF BARNSTABLE i LOCATION 1 CU, SEWAGE # VILLAGE AS SSOR'S MAP& LOTS INSTALLER'S NAME&P NE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER i PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by QG1 -e j I, Aga as g C c31 39 6 lb i (fig 30 { I (kC 1� �d . c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2127/13 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information `\ forms on the v\ computer,use 1. Inspector. only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Citylrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority P 2/27/13 rm ectoFs Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 tle Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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 MEET MINIMUM PASSING REQUIREMENTS AT TIME OF INSPECTION. TAKE NOTE THAT THE SYSTEM IS ORIGINAL TO THE HOUSE AND WAS ONLY OCCUPIED BY ONE ELDERLY MAN FOR SOME TIME HOUSE HAS BEEN VACANT FOR SOME TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): r s t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ - ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool s ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 0 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. &ns-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: THE PREVIOUS INSP REPORT SHOWED A SEPTIC TANK D-BOX AND LEACH PIT, I WAS ABLE TO LOCATE A SEPTIC TANK AND PIT, NO D-BOX WAS FOUND, THE TOWN FILE ON THE PROPERTY HAD AN AS-BUILT CARD THAT WAS FOR THE WRONG PROPERTY SO I AM GOING OFF OF WHAT I ACTUALLY FOUND Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: HYANNIS WATER WAS CALLED AND BASICALLY NO WATER HAS BEEN USED OVER THE PAST 2 YEARS THE PROPERTY WAS BILLED FOR 1 UNIT PER YR FOR THE PAST 2 YRS-1 UNIT= 100 CUFT Sump pump? ❑ Yes ❑ No Last date of occupancy: NOT RECENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ElYes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: HOUSE VACANT FOR SOME TIME Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): TANK AND PIT WERE FOUND t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts w u Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: SYSTEM APPEARS TO BE ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: APPEARS TO BE 1000 GALLON Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1115 PITCHERS WAY Property.Address BOLAND Owner Owners Name information.is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 ONLY HAD CLEAR LIQUID AT TIME OF INSPECTION Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1115(PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 BOX FOUND Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑.No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is HYANNIS MA 02601 2/27/13 required for . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIT WAS LOCATED AND FOUND TO BE DRY AT TIME OF INSPECTION, STAIN LINE WAS AROUND 6" FROM INLET INVERT, PIPING APPEARD TO BE ORANGEBURG PIPE WITH A PIECE OF BROKEN PIPE IN THE BOTTOM OF PIT, THERE WAS PIPE STICKING OUT INTO THE PIT,CAN NOT PREDICT FUTURE PERFORMANCE OF PIT, HOUSE HAS BEEN VACANT FOR SOME TIME AND WAS OCCUPIED PREVIOUSLY BY ONLY ONE PERSON Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑. No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: AT LEAST 4 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: AUGERED 4 FT INTO BOTTOM OF PIT NO G.W ENCOUNTERED e Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1115 PITCHERS WAY Property Address BOLAND Owner Owner's Name information is required for HYANNIS MA 02601 2/27/13 every page. Cityrrown State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L _ U(kC �c ,d T2 A', 5 v { 7 / V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ^ F n � � C r� c TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 I;n —1) Z®li� �A Owner's Name: OLGA BARTOLI Owner's Address: 1115 PITCHERS WAY HYANNIS, MA 02601 Date of Inspection: 5/2/01 Name of Inspector: (please print) JOHN GRACI RECEIVED Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 JUN v 1 2001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE HEALTH DEPT. 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: 4 X Passes " _ Conditionally Passes _ Needs Further aluation by the Local Approving Authority Fails Inspector's Signature: 411 Date: 5/2/01 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. 4 f •1'; In C fncr;,Minn T-nrni (!I'V'000 �- f T.Pgge 2.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old'is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a :"Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a �4 i—Pgge 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BAiRTOLI Date of Inspection: 5/2/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 nLa. 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 forma _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes.';t 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. n Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 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)] s Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 t FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 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/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 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: 1974 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron —40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,.evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L S' 6" H 5'.7" W 4' 10"" Sludge depth: 4" 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: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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 L 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: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOW Date of Inspection: 5/2/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I e Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 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: nla 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.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 6"OF LEACHING LEFT AT THE TIME OF THE INSPECTION.SYSTEM SHOWS NO SIGNS OF FAILURE. 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 I n Page 10 of I 1 Y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS,MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 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. EA C ag O pA 2a� 46 3�8 k 39 PA is M 3r N 6C a& in Page VI I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1115 PITCHERS WAY HYANNIS, MA 02601 Owner: OLGA BARTOLI Date of Inspection: 5/2/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO 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) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET P r G j gp_c''c rr � yalj a . LEGEND SEPTIC COMPONENTS /p GARB ' e Spb"la + Caere fa . EXISTING 0 R °4 • D." s.".g`Circe°Ou' 1000 GAL OT SEPTIC TANK OWED g • EXISTING F 1a e° s ti !/y°•;.'+• `a"i,' " �e LEACH PIT/ 1 -- ;';� CESSPOOL `P F MA DISTRIBUTION BOX®' / 3. /71% %D LL6CM � ME� � TEST PIT © ,N TaL a ToE S EXISTING LEACH PIT WATER LINE —�,►r•• / TO BE PUMPED AND / GAS LINE FILLED OR REMOVED LOT 54 G OVERHEAD WIRE -OR I TS USE MA Y BE A CONTINUED WITH THE AREA = 15048 sf+- � ° ' - APPROVAL OF THE PLAN BOOK 271 PAGE 83 HEALTH DEPARTMENT. ASSA MAP Z73 Pa 203 �- lr►Fra� Irl/{�� 62 F MINIMAL `t�yf y i GRADING 3 �(�/J N VG PROPOSED O v PROPOSED SOIL ABSORPTION '`� " E SYSTEM -SEE DETAi'L ON BACK 63 5(pgLE GIS _ —- —� I �•� _7 i rn ELEVATION -G Z 65. 45 T OP OF - . I _ b 464 O D 7, o IZ. fn 0 2,116 Onx- , \ _-------- -- J -0 - COLOR IS A l�®�®� PAVEDD 1VEWAY PLAN USE COLOR PLAN ONLY FOR INSTALLATION FULL DETAIL IS BEST VIEWED IN / FULL COLOR / 3 63 FIL A N SCALE: 1 in = 20 ft 4 0 20 40 62 O 10 20 �- PRINT ON 11 x 17 in PAPER FOR PROPER SCALE kp��N OF MASS9 FP��H OF MASS DAVID �yGJ, o DAVID D. SEWAGE DISPOSAL COUGHANOWR r COUGHANOWR N % J ' SYSTEM PLAN No. 1093 No. 461 o -TO SERVE EXISTING DWELLING so/qp via S A R A H E. BEAL DWNERISI OF RECORD 1115 PITCHERS WAY 155 Geo Ry der Rd THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM PROPERTY ADDRESS DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING Chatham, MA 02633 PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS, OWNER DQVIdCOUL®H^otmOII.G((�O�m4 DATE: MARCH 5, 2021 SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOH 364—OH7 PG.1LZ JOB>/ ETE-4535 M.a SOOIL TEST L@@ 46 ' ' pD [EGIONN CALCULATIONS SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DAVID STANTON, HEALTH DEPT. TEST PIT 1 NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PERC AT 64 in - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL 62.90 INCHES HORIZON TEXTURE (MUNSELL) MOTTLES NEW 1500 GALLON SEPTIC TANK. 0-8 FILL DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 8-16 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: 59.40 16-42 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 142-1241 C MEDIUM SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 52.57 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. TEST PIT 2 NO GROUNDWATER OUNTERED THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY MIN/INCH DEPICTED BELOW CAN LEACH: ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 62.75 INCHES HORIZON TEXTURE (MUNSELL) MOTTLES BOTTOM AREA = (24xl2.83)-1/2(3X3) = 303.4 sq. ft. 0-6 FILL SIDEWALL AREA = (24+21+12.83+9.83+4.24)x2=143.8 so. ft. 6-15 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE TOTAL AREA = 447.2 sq. ft. 59.58 15-38 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE FLOW CAPACITY = 0.74 x 447.2 = 330.9 gal/day 38-126 C MEDIUM SAND 10 YR 5/4 NONE LOOSE INSTALL THE PROPOSED LEACHING GALLERY AS CONFIGURED 52.25 BELOW. FLOW CAPACITY = 330.9 gal/day WHICH EXCEEDS THE 330 gal/dog REQUIRED FOR A THREE BEDROOM DESIGN. 1000 GALLON SEPT§C �,7TA1 K .SOM ASSSORP§0N EXISTING`"UNIT DIMENSIONS & DETAIL a.0 STEM`''CONSTRUCTION"DETAIL." TANK TO BE PUMPED DRY AT TIME OF INSTALLATION USE.SHOREY PRECAST 500 GALLON LEACHING DRYWELL AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. 3 ft DRYWELL REPLACE .WITH.A NEW 21.0 ft NITS I in 1500 GALLON TANK A L TAPER �, P IF CRACKED, ROTTED NZ a!L OR OTHERWISE COMPROMISED. OD „ f w w Cn ,y o 41.. NOT- TO NE 3.5 ft 8.5 ft 8.5 ft 3.5 ft SCALE 5 O 500 GALLON 8 f rtr O DRYWELL t- DIMENSIONS & DETAIL 6 j L n Q INSTALL ONE INSPECTION RISER TO WITHIN THREE INLET OUTLET USE INCHES OF FINAL GRADE H-10 & INDICATE LOCATION CO V R E COVER ON AS-BUILT =LINE UNIT IN DRO w FL -► 0, 33 _ lr( „ BUILDING 10 in _ 14 TO Its .t,. ; in '^ D-BOX D 48 in I--," ,GAS.._.-_.--._ 5� i LEVEL BAFFLE 102 /n CROSS SECTION VIEW b in STONE BASE IF NEW INSTALL AN APPROVED GEOTEXTILE-\ FABRIC OVER STONE SEPARATION BETWEEN INLET & OUTLET TEES NO LESS THAN LIQUID DEPTH CROSS SECTION VIEW - - . 8 314 in TO ® 24 in • 314 in TO 2 1-112 In GRAVED: DEPTHTIVE.�1-1/2 in GRAVEL p p p �p /� 46 in 58 in 46 in ����U1T��V.TIlO1lU U 0 _UDB-3�20y DIMENSIONS PIPES EXITING D-BOX TO.RUN LEVEL 150 in .AND DETAIL FOR 21 FEET BEFORE!PITCH/NGo,DOWN 12 In MIN " -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE T' lJ STARTING WORK. FROM N TANK � h � � 70, -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM p ^ REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC SAS �Q) 0 CODE (310 CMR 15). "° " -INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND Y UTILITIES BEFORE EXCAVATING FOR SYSTEM. \� b In STONE BASE _ ECO-TECH RAPID RESPONSE RECOMMENDS THE INSTALLATION CROSS SECTION VIEW Q OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC PUMPING OF THE SEPTIC TANK. SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. IF LO p TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 4C PVC EL = 65.45 +- 6 in OF FINAL GRADE. AND TO PITCH AT 1/8 in MIN 63.00 D-B0 3' MAX E�{ TWG USE H-20 . 60.00 EXISTING 1100100 GALL0W 800a°p0000 a PRECAST °00000�aa8 SEP= TANK 62.60 DRYWELL 00 000a 0o 0000�o�°oo oo opo°o°000 a0000°°oo°o b2.40 EXISTING REFER TO DETAIL BOX TONE SOL A°- BS%0RPTU0N +S 62.57 59.25 6 In STONE BASE IF NEW BASE.w SYSTEM -REFER TO EXISTING I ft 55 ft DETAIL BOX ° 57.25 NO GROUNDWATER Ln BELOW MOTTLING OBSERVED _ 52.25 SEWAGE DISPOSAL SYST_E_M PL_A_N11 1115 PITCHERS WAY HYANNIS, MA MARCH 5, 2021 ETE-4535 PG 2/2