Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0095 QUAIL LANE - Health
95 Quail Lane Aqua-Leisure IND. Hyannis A=288 -213 a I 4 Town of Barnstable y Department of Regulatory Services OAM Public Health Division Date r .aM 200 Main Street,Hyannis MA 02601 Date Scheduled I- , ` ` J; 6/ 7� Time Fee Pd. 0(-,) • f Soil Suitability Assessment for Se e Apo l { Performed By: I fGt Y'�'.a.Jx ���� Witnessed By: LOCATION&GENERAL INFORMATION , Location Address Owner's Name q(v Q,)Al L_LiJ. V l kZ�Y \/i V rz A, SiZ: H7fWNts�eTt t lf� Address A' 1 Assessor's Map/Parcel: MAP •Zi3£- F-Pt9Q '-217 Engineer's Name W cl s c'Y� •- r ;GGI V NEW CONSTRUCTION REPAIR Telephone# 7(Jf3--3"Z ri-L Z tQc=YJ1►�"L- acnsLes c�r1 .Land Use Slopes(/) � ' �� � Surface Stones Ms N}P Distances from: Open Water Body 10 D It Possible Wet Area r'Sb ft Drinking Water Well%I It Drainage Way. >1t2o ft Property Line ?/jQ ft Other ft SKETCH:(Street name.dimensions of lot exacrlocations of test holes'&perctests,locate wetlands in proximity to holes) . T Parent material(geologic) (HL Ci S� -- Depth to Bedrock /A- . Depth to Groundwater:Standing Water -. /11/L Weeping from Pit Face Estimated Seasonal High Groundwater N,14, DETERMINATION FOR SEASONAL HIGH WATER TABLE ~ Method Used: :?._. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side ofobs.hole: in. Groundwater Adjustment , ft. . — Q Index Well# Reading Date: Index.Weil level Adj.factor Adj.Groundw7p�i Y:el_ iw PERCOLATION TEST Date Time!'` t Observation ' - J Hole# j 1 a_ ..Time at 9'• �� � ,r tl _ Depth of Perc .ry`rt���� Gi= Time at 6 Start Pre-soak Time @ j9"* NV /10 t 7 .rime,(9"•6") A t� End Pre-soak / l0/.Z�(�J rn RateMin./lnch Site Suitability Assessment: Site Passed X Site Failed Additional Testing Needed(Y/N) Original: Public Health Division. Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. QAS EPTICU'E RC FORM.DOC DEEP OBSERVATION HOLE LOG Hole.# Depth from Soil Horizon Soil Texture Soil Color'T Soil Other Surface(in.) (USDA) (Munseiq Mottling (Structure,Stones,Boulders. 7T+ Consistency.%Gravel) 6,41 olix z �;71 O DEEP OBSERVATION.HOLE LOG Hole,# 2 Depth from f Soil_'Horizon' Soil Texture Soil Color Soil Other Surface(in.) (USDA)-, (Mansell) Mottling (Structure,Stoncs,Boulders. Consistency%Gravcl), tit`'� 35 ' �y to /g ' SGt,N +, DEEP OBSERVATIONMOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones.Boulders. Consistency%Gravel). Q L— U, ` z LF PA Se,.,.s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones.Boulders. C- --------%Gravel) ° 5 - 134 A u iL$ t, C F_M ; 'l fin S 2- Flood Insurance.Rate Man: Above 500 year flood boundary ,No_j Yes Within 500 year boundary No tj°Yes_ Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? I;If not,what is the depth of naturally occurring pe ious material? Certification tt 1.certify that on t (date)I have passed the soil evaluator examination..approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tram expertise and experience described in 310 CMR 15.017. Signature — /i, t Date Q:\S E PT I CP E RC FO R M.DOC Commonwealth of Massachusetts Title 5 Official Inspection F 0rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is H annis MA 02601 7/30/13 required for every y page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms _ 05�on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the retum,, Name of Inspector key. Robert Paolini Septic Service Company Name 17 Playground Lane Company Address Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number cNa B. Certification ': W III t� I certify that I have personally inspected the sewage disposal system at this address and that then` 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 ortslte sewage disposal systems. I am a DEP approved system inspector pursuant to Sectio-A.,�5.340,of Title 5(310 CMR 15.000). The system: Fx� Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/30/13 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner 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. /�, 1 t5ins•3/13 TVInm:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: i 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): I i, i t5ins•3113 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 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Tide 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 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 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 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s . Number of times pumped: . PpO p p ❑ ❑x 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. ❑ ❑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 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large .system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Tide 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 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date ofdnspection 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 ❑ 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? ❑ 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) N ❑ Was the facility or dwelling inspected for signs of sewage back up? n ❑ 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: ❑ ❑x Existing information. For example, a plan at the Board of Health. ElDetermined in the field(if any of the failure criteria related to Part C is at issue nX approximation of distance is unacceptable)[310 CMR 15.302(5)] U. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes M No information in this report.) Laundry system inspected? Z Yes ❑ No Seasonal use? ❑ Yes 2 No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: na Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Left System) ,p — Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required fo every Hyannis MA 02601 7/30/13 r page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes l5X1 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'" 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gl. Sludge depth: 3" !Sins-3/13 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 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condution, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of leakage.Tank appears structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 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 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 95 Quail Lane(Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.Box has two outlet laterals.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pits were dry at time of inspection.Pit#1 stain line was 22" below invert.Pit#2 is under patio for pool. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dsposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a+ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is Hyannis MA 02601 7/30/13 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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: 011 hand-sketch in the area below — dra:4 nc attached se.cara'ely I Flo �- v, �i Title 5 official inspection Form:Subsurface Sewage Disposal System'Page 15 of 17 t5ins•3113 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope ❑x Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) M Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Left System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for very Hyannis MA 02601 7/30/1� e page, City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed 0 System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °- 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30113 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: 0,7 key to move your cursor-do not Robert Paolini -514 use the return Name of Inspector key. Robert Paolini Septic Service Company Name 17 Playground Lane Company Address rya Yarmouthport MA 02675 City/Town State .-4 Zip Code . 508 362-3555 S14454 e 3 CD Telephone Number License Number y z B. Certification I certify that I have personally inspected the sewage disposal system at this address and th6pthe 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: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev luation by the Local Approving Authority 7/30/13 Inspector's Si6ndure 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-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane(Rear Right System) ,p — Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/;13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑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: 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): i �I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 1.TO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for very Hyannis MA 02601 7/30/13 e page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 on obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): , ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): �I 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•3/13 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 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than'/day flow t5ins•3/13 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 95 Quail Lane(Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ElRequired pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ ❑x 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 alprivate 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 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.] ❑ ❑x The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 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: i 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 sewagelback 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? FX-1 ❑ 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: ❑ ❑x Existing information. For example, a plan at the Board of Health. ❑ 0 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u,�>''� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30113 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Fx1 No information in this report.) Laundry system inspected? ❑x Yes ❑ No Seasonaluse? ❑ Yes ❑O No Water meter readings, if available last 2 ears usage d na 9 ( Y A (gP ))� Detail: Sump pump? ❑ Yes ❑X No Last date of occupancy: na Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Quail Lane(Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ❑x concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gl. Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" 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.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of leakage.Tank appears structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts z UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane(Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30113 page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 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 95 Quail Lane(Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/36/13 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 No i Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): { Box is level.Box has one outlet lateral.No evidence of leakage. I I 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.): 1 I� *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit were dry at time of inspection.Stain line was 20" below invert. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 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 95 Quail Lane(Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7,130/13 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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 .S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t5ns•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is Hyannis MA 02601 7/30/13 required for every H y I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope ❑x Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Quail Lane (Rear Right System) Property Address AQUA LEISURE INDUSTRIES INC Owner Owner's Name information is required for every Hyannis MA 02601 7/30/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is required for HYANNIS PORT MA 6/10/11 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information 'I forms on the 11� computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name � P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip,Code 508-420-4534 S14297 d Telephone Number License Number k I j I 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 Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving3Authority(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•09108 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 1 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT MA required for 6l10/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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: HOUSE HAS 2 SYSTEMS BOTH OF WICH MEET OR EXCEED MINIMUM PASSING REQUIREMENTS AT THIS TIME, HOWEVER BOTH SYSTEMS ARE FROM 1974 AND ACCORDING TO CARETAKER HOUSE HAS ONLY BEEN USED FOR WEEKENDS AND FUNCTIONS . I AM UNABLE TO PREDICT HOW THE SYSTEMS WILL FUNCTION UNDER FULL TIME USE, WITH THE SAME OR INCREASED WATER USAGE B) System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT MA required for 6/10/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): i ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water f ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09ff18 Titlee 5 Offivpl 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 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is required for HYANNIS PORT MA 6/10/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ ® 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 Y day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I� Commonw ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 95 QUAIL LiJ Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 I every page. Cdyfrown State Zip Code Date of Inspection B Certification (cone.) j Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ IIEI 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 aIDEP 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. i 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 El ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. "� �UO Te 5 01-1&ei niayetiuuit F66f `Subsuil%id Sev-9.Gs4a;Sysietn raye 5 ui 17 - Commonwealth of Massachusetts Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Properly Address AQUA LEISURE INDUSTRIES Owner Ovmer's.Name information isreqired for HYANNIS PORT MA 6/10/11 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: w ❑ E;.isting 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. Cltyrrown State Zip Code Date of Inspection R_ System Information Description: ACCORDING TO AS-BUILT CARD HOUSE HAS 2 SYSTEMS ONE WITH A SEPTIC TANK D-BOX AND 2 PITS AND ONE WITH A SEPTIC TANK AND 1 PIT, BOTH SYSTEMS WERE LOCATED 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: Sump pump? ❑ Yes ❑ No Last date of occupancy: LIMITED USE Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official insp ection Form:Subsurface Sewage Disposal System 4Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Properly Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: BOTH SYSTEMS WERE INSTALLED IN 1974 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: Sludge depth: LIGHT IN BOTH TANKS t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. cltyrrown 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 0 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.): BOTH TANKS ARE CLEAN WITH NO SIGNS OF LEAKAGE AT THIS TIME ONE SYSTEM WAS PUMPED IN 2010 ACCORDING TO CARE TAKER, BOTH TANKS LOOK TYPICAL OF AGE Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Insp ection Forth:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 QUAIL LN Properly Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distrib ution Box(If present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 11 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 SYSTEM WITH 2 PITS IS THE ONLY ONE WITH A D-BOX Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•09J08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yY 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. Cdy/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): THE PIT ON THE SMALLER SYSTEM WAS OPENED IT WAS EMPTY WITH NO SIGNS OF FAILURE.THE LARGER SYSTEM I HAND AUGERED INTO THE STONE SURROUNDING ONE OF THE LEACH PITS AND FOUND CLEAN STONE INDICATING NO SIGNS OF HYDRAULIC FAILURE Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'Y 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10/11 every page. Cdy/Town State Zip Code Date of Inspection D. System Information (cunt.) 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 ' i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name information is HYANNIS PORT required for MA 6/10l11 every page. Cltyfrown State Zip Code Date of Inspecton 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•09M Title 5 Official Inspection Form:SubsurFaoe Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments nts 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner wner's Name information is O required for HYANNIS PORT MA 11 every page. cltyrrown Dat eof 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 10 FT 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: PROPERTY IS MUCH HIGHER THAN SMALL POND ADJACENT TO PROPERTY Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 't o 95 QUAIL LN Property Address AQUA LEISURE INDUSTRIES Owner Owner's Name j information is required for HYANNIS PORT MA /11 every page. cdyrrown Dat eof 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 I i i M i I I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dis g posal System•Page 17 of 17 i 1 Make application to local Fire Department. Fire Department retains original application and issues duplicate as Permit. sa°y~ APPLICATION and PERMIT Fee: 25 .00 for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: Tanlk.Owner Tank Owner Name(please print) Aqua Leisure X Signature(it applying for permit) Address Po Box 239, Avon, MA 02322 Street City State zip • • • • • ' Company Name Enviro-Safe Corp. Co.or Individual Print Print Address 14B Jan Sebastian Drive Address Sandwi9qj MA Pnnt�G �j��� Print Signature7yj f r ermit) 1 ,/ Signature(if applying for permit) L IF I'Certified Other ❑ IFCI`Certified ❑ LSP# Other Tank Location 9-5.:QuaTr Lane , Hyannisport , MA _ Steet Address J city Tank Capacity(gallons) nderg round _ Substance Last Stored #2 o 11 Tank Dimensions(diameter x leng ) I Remarks: Firm transporting waste Enviro-Safe Corp. State Lic.# MA#329 Hazardous waste manifest# 000167330JJK E.P.A.#_ MAC300001617 Approved tank disposal yard T u r n e r , Inc- Tank yard# 002 Type of inert gas Tankyardaddress 235 Commercial Street , Lynn, MA / /f'q/rc 7 �L 07349 City or Town h0 ) 4NA/( C� FDID# 9�a Permit# Date of issue t�(/ - Date of expiration W' -G:� Dig safe approval number: 20071309409 Dig Safe Toll Free Tel. Number-800-322-4844 Signature/Title of Officer granting permit "saw I NIS FIRE PRV IRE- l" AYAi'rrWt j ARE 11FRARTMENT After removal(s)("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signeAyKWAI36t4MpR.DoVAqT Regulatory Compliance Unit, Department of Fire Services, P.O.Box 1025, State Road,Stow, MA 017751vANNJS, MA 026T 'International Fire Code Institute NwjV��D.j FP-292(revised 4/97) —j �.I TOWN OF VL V , ! UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS . ASSESSORS MAP NO. PARCEL NO.. ADDRESS: VILLAGE: 14�71AJ /V/J pok-r- amm-A��.� �.UG/�ll �N�l� c��66C ; ]Co-. AVOW CONTACT PERSON 41� PHONE NUMBER LOCATION OF TANKS CAPACITY: ..TYPE- OF• FUEL. AGE: TYPE: LEAK 0 CHEMICALS DETECTION C .�� C aPO��'►� �[�!/ d CL 0/C SYSTEM! r DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. _ DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS ?LEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. Town of Barnstable oFt r Regulatory Services Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Phone: 508-862-4644 Email: health(i�town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 April 19,2006 Aqua-Leisure Industries,Inc. PO Box 84 Hyannisport,MA 02647 RE: Underground Storage Tank Removal To Whom It May Concern: Our records indicate that there is an underground storage tank located at 95 Quail Lane Hyannisport,MA 02647. This tank is listed on Parcel 213 on Assessor's Map 288 and js registered with us as tank tag#24. According to the Hyannis Fire Department,records indicate the 1,000 gallon tank with#2 Fuel Oil was installed in December 1974. Any tank located outside the Zone of Contribution that is over 30 years of age must be removed if does not satisfy the construction requirements'of Subsection D of Section 326-8 of the Town of Barnstable Code: Chapter 326 Fuel and Chemical Storage Tanks. The 1,000 gallon tank is said to be constructed of Steel,which would require a removal. If the tank has been removed,you are required to provide documentation, of the removal,to the Health Department and the Hyannis Fire Department. If the tank has not been removed,you are required to remove the tank immediately. It is necessary for us to update our records at this time and in order to do so; we will need the proper documentation of the removal. Should you have any questions, comments, of if you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, Thomas A. McKean,RS, CHO Director of Public Health r 04/12/2006 10:23 5087786448 HYANNIS FIRE PAGE 06 ' �V wa. V� aKa.�►.0�.Y.rr _ __ UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS ASSESSORS MAP NO. s PARCEL N0. . 13 - ADDRESS: VILLAGE= oaLNAME 3 . p_. Wf/ r"RhI CONTACT PERSON. W ,. PHONE NUMBER 1 ry v LOCATION OF TANKS,* - CAPACITY2 TYPE-Or FUEL AGE: TYPE: LEAK CHEMICALS d j f SYSTEM DETECTIOt ICED D .L 0A )ATE OF PURCHASE OF EACH,* 1. f Z. 3. 4. S. )ATE OF FIRE DEPARTMENT PERMITs7 'ESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS 'LEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. r/ 0 1 I' d� 9 3 ffiA .,f A � • . 3R - Find MapfParcel 288213 �k Town of Barnstable Health Department Health System , vow A9ap Parcel 288213 r wo Ta[� Nbr 01 Tag bra 00024 46 ri .-.... act ,z Te fNot�ticaton Date, `�—! Status f Date Remova Notification Date; t � W 1 W ii44 3 Tes 08/06/199 t Abandon fin— "Al wo Yar�ance� eV. Fuel,Sto d I VFuelaStoraR asson Hs f p � ton truction Leak Dete ion x, Gatlioilic Detection 9 T , �. a ankin o 001000 S ... '' 'Addition"1 D aiia ri y Addsr , o ChangeJul La J �o D S1�Q Z oc- , � C 7V 1-N-ST ALLE-�2�S-1J-L-�NI-E--�AD-D-RES-S B U-I-LD-E- 77 R-S-►.l-ll lvt E Q D-D R E-SS rL/ DACE-P-E-R-tv-1T-ISSUED D A=T-E.CO-M-P-LI-WIA-CE-1-SS-U-ED - J Q� 4 �2 LOCATION �55F-W&CIEPERNAVT 1�lO. VILLAGE WST&LLER5 U&ME 1T� ADDRESS bUILDER,S�, 1J A,IvIE ADDRESS fg D/S,TE PERt%A T-` 155UED DATE COKAPLI [NICE ISSUED �' +arm f No. FEi&.. ... ................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® H-ya, LT ..........OF...........:.... ......... Appliration -fox Uii viitt1 Workii Tutuitrurtion Vrrnift Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst Tat, .> d . ---•-- -------------------------------ZZi f e�0 L --- ------ = ocation-Addressll / or Lot No. L Address a ---•--••---•... -• ---- = -------------- ---- ----•---• ..... Installer Address �,rr d Type of uilding Size Lot-------/: --._.-Sq. feet U Dwelling AZ of Bedrooms___________ __ __________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ___________ ________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures ------------------------ W Design Flow--- -------- -----------•-__--___-_.-_--gal er pnlson per day. Total daily flow-------- ------__---.---- _.__-.-___gallons. f4 Septic Tan Liquid capacity!4040 g liIoOOns Length................ Width................ Diameter----------...... Depth.__.-..__.----. W Disposal Trench ' - o..................... Width------------_------ Total Length._. Total leaching area....----------------sq. ft. Seepage Pit No.................... Diameter..... __ 'i--- Depth belo met_...____.-_______.. Total-leaching area-------__._____.sq. ft. Z Other Distribution box (4-1�_ Dosing tan a Percolation Test Results Performed by._____. �Y� _.�f�/ ,, ___________________________ Date--------------------------------------.. Test Pit No. 1----------------minutes per inch Depth of "Pest �it-------------------- Depth to ground water----------------_....... �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----._.--_--__-._-_._... ff��'� .� . Description of Soil -" aCi/�f?.:.__. T -' ----•- x '�''n -------- -----� '< U ------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ ------ VNature 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 's ued b he�board alth. Application Approved BY 1' � 1 //--�------------- ----------- Application Disapproved for the following reasons:........................... . ---- •-- ----------•---------•-•-------------- Date----••-------- ---••---••---•---------•----•----•-----•-----•----•--- --•--•-------------•--•--••--•-•--••-•••-----••-•-----•-•-•-••--•--•..._.......---•----------------•--•-----•----...._........._... Date PermitNo......................................................... Issued........................................................ Date -- - - - ---- ------------------------------- I el . p ..L •. Fs$.. Y.................. No .COMtMONWEALTH OF MASSACHUSETTS BOARD t-6E LT OF.................... ........... Appliration -for Ii,4pniial Worko Cnla�� r rti�� rr i Application is hereby made for a.Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst at ''.�a . •-•--- ---------- - ---- --ua,l ...... .:.e----- ................................................. „ ocation-Addres +". or Lot No. Owner• Address ...... Installer Address U Type of Building Size Lot__ r!�l ...Sq. feet �N Dwellingo. of Bedrooms___________ ____.......................__Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ w Design Flow... ---------_......................gallons per person per day. Total daily flow------- dy______._________._-__-.---gallons. j 1:4 Septic Tatik I Liquid capacity/J�:Y.gallons Length---------------- Width................ Diameter---------------- Depth_..._.____-.._. Disposal Trench!No_____________________ Width.................... Total o Le T gth___ Total leaching area---------___..------sq. ft. �. : Seepage Pit No..._ •er_.....__.. Diameter..__�.!�. ___ Depth be n e ____________________ tal lea iing area._'� ______ ________.sq. it. z Other Distribution box (4 Dosing to ;( © t�- E - 9��-e Al ~" Percolation Test Results Performed b ------ /ift.:._ .......................... Date..................................... a a Test Pit No. 1................minutes per inch Depth of Test it-------------------- Depth to ground water.._______________.__.... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �s ------- 1 Description of Soi] _.. .. f �d' ----"----'- .;r__...1�. -___s�..._..I..:.... . 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 undersigned f rther agrees not to place the system in operation until a Certificate of Compliance has been-'s ued he board alth. ned_ --------• •._. ....... . ....... -• -------•-_----- O ,�G, ate Application Approved BY � F - ---------- Date Application Disapproved for the following reasons:........................... . --•--•-•-----••-•--------•-------••••- ......................................... S .. K. ___________________________________________________•.........----------•..._.._.....___._................._---------------••-...-•..............-----'-----------_..........._......---------.. ' Date PermitNo............................................ Issued........................................................ Date h� THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH OF... .... ,.......... Lt�j . . . ....... _ "ITrr#i$irafr of fflTomptiaurP l THIS IS TO CERIFY, T.at the Individual Sewage Disposal System constructed ( . or Repaired ( ) : — l at ��!le!S.'r stallejM� __r..............................................iC....__... has been installed in accordance wit the provisions Article XI of The State Sanitary -Cyo �,_- as desc tbed in theru application for Disposal Works Construction Permit No... --..e.................. dal ............ THE ISSUANCE OF THIS CERTIFQCATE SHALL,iNOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,. DATE l4ispector - .............. THE COMMONWEALTH OF MASSACHUSETTS t, a BOARD Of -HEALT ......� ............of ......----- N . ...o... _ ------ FEE-��.............. Uigpoiia • grk,i /Tonstrurfion ramie Permissiondis jUereby granted!............i--�---- i_.......................................` ..... .......... .... ----•--•-•- to Constr t ( ) or Rep 'r ( ) an dtvtd Sewa e Dtsposa System 7 a as shown on the application for Disposal Works Construction mit No _ __.. ....... Dated Dated...__ /;,�i�7C--_.... ' - r -d o�f H Boar al DATE ..................................' -.................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ....._. --�."��"""'"`" --•-••— ""'"""'"""""' .It xt�.•w A Y�' 4" `�;`+•"� �:�i" '•"•�� •, '.R 1�" � yl,"4w«,y. a ys4 .� ri+ '.�:a,;:c ,., .. +r + • '�• '6. .r .+. `.a r' . "•�' _ \^,', °+a�yr 'W i � , s,f �+_ t�a .{• � _ _ to rK ptl: ,y�. 'i "'S„y'}tYrai.!•T".y 'fi V : c. . +[./11 =":: _ ` {' = LOC^QT10N : �oy"?c 5EWI&C-4E PERMIT MC - 11`►STQLL.ER�S U/I�P/lE � ADDRESS — — Ohh�Lc — — — — �U1l.DER S Q &MF— ADDRESS D11.4'TE PERIvl1T ISSUED DATE COKAPLI W dCE ISSUED ; — — — 1 /r 7L s