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HomeMy WebLinkAbout0025 PRINCESS PINE ROAD - Health LA = rincess Pine Road s P - 69 089 r. i SEWAGE INSPECTIONS 10CATION25 P/z ince,6.a Pine Road DATE7/15/03 VILLAGE Kuann.i-5, Naa.3. 02601 ASSESSOR'S MAP & LOT INSpFe'POE h P. mr om9e z SEPTIC TANK CAPACITY 1000 aaeionh 1?.eu,6 Box LEACHING FACILITY: (type)LQaeh.ina .t/zench (Size) 65 'X4'X2' NO. OF BEDROOMS 3 ` BUILDER OR OWNER Sa zah Cunningham OWNER MAILING ADDRESS • 382 V.iti-aml Hiii Centel Sandwich New Hampzhize 03227 f r 1 �P t �, _ (� i i� � � � � � � 2-t, �� �- . � � � � � � ��� � � � .,� DATE :7/15/03 PROPERTY ADDRESSZ5 Pa.incezz Pine Road Mazz 02601 ----------- ------ On the above date, I inspected the septic system at the above address. Tnis system consists of the following: 1. 1- 1000 ga P2on ze/2t.ic tank. 2. 1-Di.6tAigut.ion Sox. 3. 1-2each.ing taench. (6 5 'X4 'X2' Based on my inspection, I certify the following conditions: 4. 7h.ie .ie a t.it2e dive Ze/21-.ic 6YZ�em. 5. The ze/2t.ic .ayztem .i,6 .in /2ao/2ea woak.ing oadea at the /2ae.eent time. 6. The ieach.ing taeneh .i's /aeZentiy clay. 9. Sy.3tem wa.6 .in-3ta2ied 8125197 SIGNATUR Name : - J_- P . _Macomber-Jr . -_-- It Corripany : )qagph Pam_M_�Sgm��r d_ Son, Inc , address :--�4x-�� ........ - _ -CusQcyLUP,_ :3a __22.632- 0066 'Cfl`N NEA1.�µ ?none : 508- 775= 3 3 3 a -------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY L P. MACOMBER & SON, INC. anks Cesipoo"'LeachfI"ds Pumped & Installed Town Sewer Connections 66 Centerville. MA 02632.0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION `i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 P z incezz Pine Road yann.iz, Razz. Owner's Name:Saaah Cunn.in r{ham Owner's Address: Centel Sandwinh New gampzhilLe 03227 Date of Inspection:7 L f o 3 Name of Inspector: (please print) ao.seNh P. Nacomge2 a2. Company Name: I. P. ft com en & Son Inc. Mailing Address:13ox 66 Cen.teavi.2.Pe, Na,6,6. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 CERTIFICATION STATEMENT I certify that 1 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 trairting and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes, Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature/Imit Date: The system inspector shall 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:25 P2.incezz Pine Road yann.cz, 111azZ. Owner: Sa zah Cunningham Date of Inspection: 7115103 Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D A S em 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: 7.hp AP_/2itiC hu,3tem 1..6 .in pnope2 woak.ing ozdea at B. System Conditionally Passes: .e)O 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. X/4 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: /0 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: /.1� The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 %2.ince.6,s Pine Road Owner: Sa/zah Cunninaham Date of Inspection: 7/9 5/0 3 C. Further Evaluation is Required by the Board of Health: A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,.safery or the envirotunent. 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: WO 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. lt0 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. AP The system has a septic tank and SAS and the SAS is less than 100 feet bu 0 feet or more from a private water supply well". Method used to determine distanceGQ "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Pa-ince.3.3 P.ine Road yann.L3, azz. Owner: Sa2ah Cunningham Date of Inspection:7/15/03 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 a� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool 44c—t;0Ixx' ,may -7—,, , _✓ iquid depth in cesspeal is less than 6"be invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped e _ �y portion of the SAS, cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ,Krty portion of a cesspool or privy is within a Zone I of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/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 I the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 "yes" in Section D above the large system.has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 P/L-inceaz /.ine /toad yann.c6, 77 ah . Owner: Sa2alz Cunningham Date of Inspection: 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 w _ -if 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 ? zWere all system components,*WI the SAS', located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge nand depth of scumspected for the ndition 2_ Was the facility owner(and occupants if different from owner)provided with information on the pro er maintenance of subsurface sewage disposal systems? p The size and location of the Soil Absorption System (SAS)on the site has been determined based on: �Yes no _ Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR I5.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress:25 P/L-ince,3.6 Pine Road >Iganni,3, 17a.6-s. Owner:Sa,zah Cu,aninaham Date of Inspection: 7/15/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 0114C��'16'�� Number of current residents: y �J Does residence have a garbage grinder(yes or no): y�E. Is laundry on a separate sewage system es or no):Ab (if yes separate inspection required) Laundry system inspected(yes or no): 1 Seasonal use: (yes or no):,D Water meter readings, if available (last 2 years usage(gpd)): 2002-75, 000 ga.P.t?on.-Po 48 qPD Sump pump(yes or no): ,114 — , ya-e ion.6— 16 4. 39 qPD Last date of occupancy:( �( � COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ,ILQ gpd Basis of design flow(seats/persons/sgft,etc.): of,$ Grease trap present(yes or no): Vd Industrial waste holding tank present(yes or no):A40 Non-sanitary waste discharged to the Title 5 syst m(yes or no):4—R Water meter readings, if available: ) Last date of occupancy/use: lul-7_ OTHER(describe): 414 GENERAL INFORMATION Pumping Records Source of information �-' Q� �q�I� log Was system pumped as part of the inspection(yes or no): .p0 If yes, volume pumped: © gallons-- How was quantity pumped determined? _,Z9 Reason for pumping: TYP�c OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool ,L,D Privy 41 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) fk Tight tank AA�Attach a copy of the DEP approval ,L20 Other(describe): X'214 Approximate age oral) components,date in t 11 f kno�� source f information:ation: l " '�4 ( Were sewage odors detected when arriving at the site(yes or no):A* 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add ress:Z5 P/t ence.s.6 Pine /toad Hyann.ia, t7a s,s. Owner:Sa,zah Cann-Ingham Date'of Inspection: 7115103 BUILDING SEWER(locate on site plan) it Depth below grade: 1417 � Materials of constructioTn:_—cast iron r/ 40 PVC X/dother(explain): ,jI4 Distance from private water supply well or suction line. t Comments(on condition of joints, venting, evidence of leakage, etc.): The6,q,6tem is Dented 2ouy e Zoo vent,. SEPTIC TANK: Zlocate on site plan)/":P4146es Depth below grade: Material of construction: //concrete.Od metal fiberglass jp_polyethylene illd other(explain) '00— iftank is metal list age:,VQ is age confirmed by a Certificate of Compliance(yes or no)44 (attach a copy of certificate) Dimensions: �64 56 Sludge dep ;,,4.[z4� Distance from top q�pudge 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 o 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.): 2 . nd and zhow,s no evidence of .2eakaye. 7he iiqu.id .t?evei at the out-get (i YktA } I&$ {locate on site.plan Depth below grade:.G4 Material of construction concrete AmetaLeR fiberglass[/ polyethylene'l�i other (explain): iIJA Dimensions: A Scum thickness: 42 Distance from top of scum to top of outlet tee or baffle: AZ$ Distance from bottom of scum to bottom of outlet tee or baffle: 4-11f— Date of last pumping:—1 Comments(on pumping recommendations, Net and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): . nI?Po tv fnrin i.t nnf'1La6aQi 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add ress: 25 PZince.a•s Pine Road yann.c , a Owner: Sa zah Cunninqham Date of inspection: 7175103 TIGHT or HOLDING TANIGQ�0-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: A Material of construction:,,Vconcrete metal fiberglass F polyethylene 41A other(explain): Dimensions: Capacity: _gallons Design Flow: .,gallons/day Alarm present(yes�or no): Alarm level: 9 � Alarm in working order(yes or no): 10 Date of last pumping:_h Continents(condition of alarm and float switches,etc.): 7iahi on hoidi'na tankz ate not R2e3ent DISTRIBUTION BOX: 2(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.): DLL,i{ni uiJn ox haA two .2ate2a.P.3 No evidence 0,1 •6oP.id,6 ca22y �Ponknav into on oily of the Sox PUMP CHAMBERfikk,,(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 10iimn rhamOvn is noi n v/,onf 8 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: 25 Lz ince.s.6 Pine Road duann-iz. (7aAA, Owner: .Srnnnh Canninnham Date of Inspection: 7/9 5 L3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1-65 'X4'X2' iggrhinU Y,?Pnrh r/ngg �l If SAS not located explain why: e Ty� -L6 leaching pits, number: ,�ffft�� leaching chambers,number: W7 leaching galleries,number: r / )t€ leaching trenches,number, length: A10leaching fields, number, dimensions: d overflow cesspool,number:innovative/alternative system Type/name of technology:l/ e Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loam U in rid Le) mnr/ium .pine Arinr/ Al., Aian,t n0e 1714rinau0ir ,O(j Piinn C1.O nnnrl n a Cni PA nne day llagafnf ioq 44 QQ Z-Wag, 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: i Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 1'0 AAnnnPA jinn »GtiL�lJldBb6722; PRIVY-MAX(locate on site plan) Materials of construction: Dimensions: .�y$ Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): %�2LUU 14 nO.t /2RPAPni 9 Page 10 or I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:25 /,%ineez.6 10.ine /toad yann.c.e,, a,3.6. , Owner,Sa/Lah_ "G �lham Date of lospcctioo:// 7 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system Including tics to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where publie.tivater supply enters the building. jq 61 t 10 TOWN OF BARNSTABLE i LOCATION Z S Pr/N BSI Pi.0 SEWAGE # i. . j VILLAGE gy--c r„�S .ASSESSOR'S MAP & LOT q INSTALLER'S NAME&PHONE NO. Me e k Cy aA s,,- ?7! yizt SEPTIC TANK CAPACITY DO O LEACHING FACELITY: (type) ?"f-Ute h i7lA flLJ-(size) i . NO.OF BEDROOMS ^� BUILDER OWNER PERMTTDATE: /! / 9 COMPLIANCE DATE: Oo-�9 7 Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility . r Feet Private Water Supply Well and Leaching Facility (If any wells exist t on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of l�eachin facility) Feet Furnished by mot,. i i I t ��v • �at6 i1 zP —mod Page 1 I of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) Property 25 P/Lincezz Pine Road Address: yann-..6, a.6e. Owner: Sa2ah CUnningham Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water 114p, feet Please indicate(check) all methods used to determine the high ground water elevation: q,L Obtained from system design plans on record-If checked,date of design plan reviewed: 7/15/0 3 yL-Observed site(abutting property/observation hole within 150 feet of SAS) qL-1-Checked with local Board of Healh-explain: 7/1 5/0 3 y Checked with local excavators, installers-(attach documentation) y Accessed USGSdatabase-explain: h4.t12://.down. gaanz.ta&.Pe, ma, uz. You must describe how you establishes the high groundwater elevation: ,3ed: Gah o- 12/16/94 Gaound wa4e2 e2eva4ionz agove Sea Jeve.P. bed: US9S ' (MAonurifinn mo Pf rJr)fn 2tino 9997 bed: LLSGS • ,6 Leaching 72ench :cct 5'X4 'X2' u c Groundwater`Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft pe r r Fnmptcr Method Therefore, the vertical separation distance between the bonQnl�a f Of the leaching pit and the adjusted groundwater table is �,✓�/ feet. it rasa r+'—n r�Tr'ttn-arn•ntrnTT.T rRrnnarrlrrran..►IaalTal.T1��y>7��Rn TOWN OF /3¢an�t¢17~�e BOARD OF HEALTH _ TAR SUBSURFAU 9FNAGE DISPOSAL SYSTEM INNSPECC!'ION FORM - PART D •- CERTIFICATION I -TYPE OA PAINT CI.EAALY- PROPERTY INSPECTED STREET ADDRES$ 25 P a.incezz Pine Road Ryaani� , Na s.s. , ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Saaah Cunr&i;ngham >o� PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J P Macomber & Sola Inc'.` COMPANY ADDRESSBox 66 Centerville Mass . 02632 Stregt Town or City Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ID his address rind that t)1e information reported is true , accurate , and omplete its of the time of .inspection . The inspection was performed and any ecommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ,—_,System PASSED The inspection t+hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form, System FAILED* The inspection w)liclt I have con cted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection orm , Inspector Signature Date :Yne ereDa of this tification must be provided to the OWNER, the IIUYER pplicable ) and the BOARD OF HEAL-1-H. * If the inspection FAILED, the owner or""operator shall upgrade ' syste within one year of the date of the inspection, unless allowed orthe requiredm otherwise as provided in 3.10 CMIR 15 . 305 . partd .doc f iVEJ i4AY 3 2000 f TOOOF, kv COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 L91 Name of Owner MARK KUMPEY&HELENE VAN NESLE Address of Owner: 220 OCEANWOOD DR.SCARSBOROUGH MAINE Date of Inspection: 417100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number:, 608-664-6813 FAX 608-564-7270 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 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: X Passes _ Conditionally Passes _ Needs Further Evaluati n By the Local Approving Authority Fails Inspector's Signature: Date:4/10/00 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 of the Department of Environmental Protection.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 Inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7/00 INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. nLa 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 n& 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 revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: a Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance n1a(approximation not valid). 3) OTHER n/a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 417/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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 1/2 day flow, X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.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. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 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: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. j. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner: MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7/00 Check if the following have been done:You must indicate either"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 _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection: 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 Soil Absorption System,have been located on the site. X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY Ili HELENE VAN NESLE Date of Inspection: 4/7/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 64", Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 48" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank Is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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 dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY 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: (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.) nla I revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,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 revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 417/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:n/a Garbage grinder(yes or no):NO Laundry(separate 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 two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: 4/6/00 COM M ERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:nla 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:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: THE SYSTEM HAS BEEN MAINTAINED EVERY TWO YEARS. System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL-1976 WITH A REPAIR IN'97 PERMIT 96-1817 §EWAye edel§d@(@Eted WIN iffiviEd it 4h@§Rd:(y§§OF fl8): N8 revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(n/a)n/a leaching chambers,number: (nla)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (2)65 leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a 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 TRENCHES ARE FUNCTIONING PROPERLY.THE TRENCHES ARE 4'X2'X 66'IN SIZE.THE SYSTEM SHOWS NO SIGNS OF FAILURE,THE SOIL PROBED DRY IN LEACH ARE. CESSPOOLS: _ (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. nla Dimensions of cesspool: n/a Materials of construction:. n/a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)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.) nla revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 417100 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) o I� r C tic, AA I� AC 3L gA 3°L P�3�1 6C 3� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PRINCESS PINE RD. HYANNIS, MA 02601 M269 P089 Name of Owner MARK KUMPEY&HELENE VAN NESLE Date of Inspection: 4/7100 NRCS Report name: n/a Soil Type: Na Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow— Moderate— Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators;installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET revised 9/2/98 Page 11 of 11 = COI'_%SO:.\"EALTH OF MASSACHLSETTS EkECUTIVE OFFICE OF E,\'VIRO\MENTAL AFFAIRS, F DEPARTMENT OF ENVIRONMENTAL PROTECTION f ONE WINTER STREET. BOSTON MA 0210E 1617i 292-550v TRUDY CORE Secretan ARGEO PAUL CELLUCCI DA'klD B STR*HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 25 Princess Pine Name of owner Mark Kumpe 1 Hyannis Address of Owner: 22 nceanwood Dr . Date of Inspection: %—G=&-<) Scarborough, ME 04074- Name of Inspector:(Please Print)WM. E . Robinson Sr. 1 am a DEP approved system)inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) company Name: Wm. E . Robinsoneptic Service Marling address: PO Box 0 9. Centerville.—AA Telephone Number: 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 _ Fails01 Inspector's Signature: & t I, Date The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 of the Department of Environmental Protection. The original should be sent to tfie system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS �g1000 f revised, 9 2. 98 Page 1 of 11 • ^!ed on Recycrcd Pane, t F� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icon need) 'ropertyAddress: 25 Princess Pine ,- Hyannis �1M11ef C Mark Kumpe l Date of Inspection: INSPECTION SUMMARY: Check AC)B, C, of A A. SYSTEM PASSES: y/I have not found any information which indicates that any of the failure conditions.described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon c mpletion of the replacement or repair,as approved by the Board of Health, will pass. indicate ye , no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined'",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance latteched)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying 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 a revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorttinued) Property Address: 25 Princess Pine , Hyannis Owner: Mark Kumpel Date of Inspection: C. RTHER 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 the public health, safety and the environment. 11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revise:_, 9/2/98 pagcsortt a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prop"Address: 25 Prinmess Pine, Hyannis OwnEr: Mark Kumpe l Date of Inspection: D. SYS FAILS: You must in icate either"Yes" or "No" to each of the following: I he a determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this dete urination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system.component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or.available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 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 analysis. 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. E. LARGE SY TEM FAILS: You must Indic to either "Yes" or "No" to each of the following: The f flowing criteria apply to large systems in addition to the criteria above: The ystem serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public heal and safety and the environment because one or more of the following conditions exist: Yes N 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 11 of a public water supply well) The owner o operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the a artment for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART 8 CHECKLIST ?roperty Address:2 5 Princess Pine , Hyannis Owner: Mark Kumpel Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. y _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrialwaste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of-the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _Y _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] The facility owner (and occupants,if different from owner) were provided with information on the propernmintenaarAi-4f Subsurface Disposal Systems. revised 9/2/98 Pagc5 of'11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address:2 5 Princess Pine , Hyannis Owner: Mark Kumpel Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:6/S6 g.p.d./bedroom. Number of bedrooms (de ign): 3 Number of bedrooms (actual):3 Total DESIGN flow IL/ 0 Number of current residents: &- Garbage grinder(yes or no):eo Laundry(separate system) (yes or no):kJ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/t/O Water meter readings, if available (last two year's usage (gpd): 1 999-2000 83 ,250 iTal. Sump Pump(yes or no): y v 1998-1999 118, 500 gal". Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type o establishment: Design ow: god 1 Based on 15.203) Basis of esign flow Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da a of occupancy: OTHE • (Describe) Last occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: &ZA System p ped as part of inspection: (yes or no)%*.d If yes, volume pumped: gallons Reason for pumping: TYPE 0 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other" APPROXIMATE AGE of all components, date installed lif known) and source of information: I•q i J-• Sewage odors detected when arriving at the site: (yes or no) .�1.0 revised 9/2/9E Page 6ofII f • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address:25 Princess Pine , Hyannis Owrw- P Jar k Kumpe l Date of Ins on: _ BUILD G SEWER: (Locate n site plan) Depth be ow grade:_ Material f construction:_cast iron_40 PVC_other(explain) Distanc from private water supply well or suction line Diamet r Com nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) t / Depth below grade: 3 / Material of construction:_✓✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: LI Scum thickness: 1-3 Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom, of outlet tee or baffle: )�l— How dimensions were determined: Q pe P b" 'omments: (recommendation for pumping, condition of inlet and outlet tees o affles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /ts—Cr—y � 3 O f GR E TRAP: (locat on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dime ions: Scu thickness: Dist ce from top of scum to top of outlet tee or baffle: Dist nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: Co ants: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage,etc.) revised 9/,2'/98 Page 7or11 . { At SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontimmd) 'roperty Address: 25 Princess Pine , Hyannis Owner: Mark Kumpe l Date of Inspection: G`—G- G--) TIGHT,,COR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate site plan) 'Depth be w grade:_ Material o construction:. concrete_metal_Fiberglass_Polyethylene_other(explain) Dimension Capacity: Lnt gallons Design flogallons/day Alarm pre Alarm levAlarm in working order: Yes No Date of p evious pumping: Comme s: (conditio of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: Inote if level and distribution is equal, evidr of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHA ER:_ (locate on site plan) Pumps in wor ing order: (Yes or No) Alarms in wo ing order(Yes or No) Comments: (note conditio of pump chamber, condition of pumps and appurtenances, etc.) revise6 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) toperty Address:2 5 Princess Pine , Hyannis Owner: Mark Kumpel Date of Inspection: Ll—G —6-1- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries, number:_ leaching trenches,number, length:L leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition f soil, signs of hydr ulp failure, level of ponding, damp soil, condition of vegetation, etc.) C e mil. .i'1 f C POOLS:_ (local on site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of olids layer: )epth of cum layer: Dimension i of cesspool: Materials c f construction: Indication f groundwater: ii flow (cesspool must be pumped as part of inspection) i Comment (note co ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) .Materials of construction: Dimensions: Depth of olids: Comment : (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revsA L 7 C pagc 9 of 11 € SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrunued) 'ropertyAddress: 25 Princess Pine , Hyannis 'Wrw: Mark Kumpel Jate of Inspection: e,_, SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water Supply comes into house) 31s r; 3 revised 9;2/98 Page 10ofII r£, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) roperty Address: 2 5 Pr inc e s s Pine , Hyannis °"r1ef C Mark Kumpe l Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells O� Estimated Depth to Groundwater A Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you establ�is/heed the High Groundwater Elevation. (Must be completed) v 1 F. revised ed 9 2 9s Page 11 of 11, r TOWN OF BARNSTABLE LGCATION o2,T /fir/nee Piw e SEWAGE # w��-��17 VILLAG I'S ASSESSOR'S MAP&LOT f 1�16 D, INSTALLER'S NAME&PHONE NO. Lee a- Ta�!c y �h s ( yi zA' SEPTIC TANK CAPACITY 00 U LEACHING FACILITY: (type) �I (size) #NO.OF BEDROOMS--I B UILDER OWNER �-�- PERMPTDATE: 1���7�gs COMPLIANCE DATE: �/��97 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 f on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by �� d � � C) No. / L w• * Fee THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS f 01pplicatton for Mtgpogar *pgtem Cow6truction Permit Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: Location Address or of No. Owner's Name,Address and Tel.No. t.A-Ct041 fJ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type df Building: c�7 Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil �- �-- � . Nature ofRepairs or Alterations(Answer when applicable) yj0 L_ W �C"i-r �L� -J_.?.ev_1rjt s✓4- iAC Ewe tt 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 iss bX this Board of Health. Signed Date ♦ t(I Application Approved by 9� Application Disapproved for the following reasons. Permit No. 17 Date Issued 11 TOWN OF BAR��NSTABLE ,l / LOCATION `�! 11, /Gt'� SEWAGE # ''VIL LAGE R1�✓MX'5 �s ASSESSOR'S MAP & LOT/Z D� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) AD NO.OF BEDROOMS BUILDER O O�W� E 5 q PERMTTDATE: ir"Z/—e7 COMPLIANCE DATE:separation Distance 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 i 6a d � ��r,� pv,�;�'y--.,�1..:�'�-`: ',. r' •"( ..r -. ,..ir..�rt'" Fee No. --THE COMMONWEALTH OF MASSACHUSETTS"', PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETZS _� ,, .application for Migooal 6pelem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: ." "Location Address or of No. Owner's Name,Address and Tel.No. Installer's Name,Add egs,and Tel.No. `--be'signer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms �. Garbage Grinder( � k ti Other Type of Building No.of Persons Showers( ) Cafeteria( ) ;a ` Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of rr k" Nature,of Repairs or Alterations(Answer when applicable) `A'�`D O►J ti Of 4 w >< z ' tx.�-� rr,.14- "_(AC *411e 1f g ig i7w� S 1 r Date last inspected: I reement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system r J 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 h'as been iss d bv this Board of Health. r. Signed -J Date / 1cu Application Approved by 9--' Application Disapproved for the following reasons 4 " Permit No. /, 1 / Date Issued 1 ,i f THE COMMONWEALTH OF MASSACHUSETTS j ;PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i Certificate of Compliance - 1~ THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(V )On by t-tt o-tc.c-tt Y for at— 7-5- ea-t'1`l C C SS phl t, -NC.eA*341� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 7 dated Use of this system is conditioned on compliance with the provisions set forth below: i Fe , ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS r i 'Wi4pont *P.5tem Construction Permit Permission is hereby granted to mrJ S Z S` ,9-1W to construct( )repair( an On-site Sewage System located at P —'t4JN\S q 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. All construction must be completed within two years of the date below. i Date: / -7 Approved by ��./ 'L. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I hereby certify that the application for disposal works construction permit signed by me dated_ t 3 4 concerning the property located at `-S- 1�kpv'j'meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system r. • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED : t DATE: 01311 � LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i, QA x �, TOWN OF BARNSTABLE �, I' / BAR W 32 Ordinance or Regulation, WARNING NOTICE ." V [N Name of Offender/Manager 0/ �V Address of Offender ,� ' /Pry 5cItila S+P� MV/MB Reg.# Village/State/Zip Business Name S y� am/(01, on / o 19 Business Address l A ,2P Signature of Enforcing Officer Village/State/Zip Location of Offense ,,,9.9 Enforcing Dept/Division Offense �116 1��� Qlr7YE-`taq U- n� 1 0 Facts 6&11� u (rl �f�' y- h���` Ss P_(' a,-o)0 -� Audlin., Ause ►�°-m4 i h 7 d a.,y.S' his will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts .and: warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. TOWN OF BARNSTABLE -+j � B W 33.2 Ordinance or Regulation / J� i WARNING NOTICE V 4JI'Vn� Name of Of fender/Manager 1!!< ;,H rl C�{ f"� Address of Offender }//y' t^Y) SCf/I --� 41, `64 MV/MB Reg.# Village/State/Zip Business Name am/�, on 19 --`� �'} r Business Address Signature of Enforcing Officer Village/State/Zip._ Location of Offense , } r't�:�f// �� 0`yQ/}n��; ✓ - 'e Enforcing Dept/Division Offense ( OL /f© t°� a: I�' ,t► !wh t�t F , ,J .f- l/t.c r�t 1 Facts tut u TJ fl r -t Ze ;This will serve only as a warning: At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town, Ordinances, Rules and Regulations. Education efforts and warning notices are : attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. TOWN OF BARNSTABLE BAR-W 32 �w. Ordinance or Regulation WARNING NOTICE Name of Offende=/Manager Sl,QL"Vo (Jlien, Address of Offender 1)1k 10ki zilla MV/MB Reg.# Village/State/Zip_ GAS in,I J /`!/ eZ2 U Business Name 3G am/ on U 19 1 � 0 Business Address t %0 ,r t %'' h' �'t�•�-xx -`g z Signature of Enforcing Officer Village/State/Zip Location of Offense p? ;✓� �,i-� ';/l/ J 71,42' 7. ►� Enforcing Dept/Division Offense oa/nf�iu�f� e Facts 746 his will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. r ✓) �7 12 4U7VI T i"C- b µ o Ke wMES-1,Pv °- �i �a A ,�q �4e. ski �n