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HomeMy WebLinkAbout0217 SCUDDER AVENUE - Health 211 7 Sc'udder Avenue Hyannis A= 289— 080 i O /II �4EAD No.53CR UPC 17743 �"fi'T.ja,1•'r'�' c� � g � � � � � � ,� S g1- �l �--� 4 � V � y �,� /�`� jj\\� 'y 1 i� 1 O � �, 1 �. �� f� TOWN OF BARNSTABLE LOCATION , e SEWAGE#Zt:3(3- VILLAGE y A"V,N ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.�.�,.eG5�.��, SEPTIC TANK CAPACITY CsZIM ASS LEACHING FACILITY:(type). h cscl ?�5. (size) NO.OF BEDROOMS OWNER J�9.,.,� ZP�t®►syS���� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within -300 feet of leaching facility) Feet FURNISHED BY L',yssz � � b c TOWN OF BARNSTABLE LOCATION 'ag^j Sc_t�� t- r iv c� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL l®T6 IV Pff ff*bhER-'S NAME&PHONE NO.V,,W_- C n SQ V, SEPTIC TANK CAPACITY LEACHING FACILITY:(type)L,= (size) , - 6Cr-t) NO.OF BEDROOMS I OWNER. PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility >S11 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED Ol CIIN 0 oo- l j TOWN OF BARNSTABLE � LOCATION a9. 1 - tcd A-- ll, SEWAGE # VILLAGE- ASSESSOR'S MAP & LOTc� cy INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL P LIC WATER P& BUILDER OR OWNER G� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ---� ``''� . - !/ Xf"� ' } S rr..�-r __ ✓�v' t. .. �,�� � i ,' � � � Y �� . �� � :- f ,� ,: .,, ,- ? • . , .� � . .. . TOWN OF BARNSTABLE LOCATION cal 1'7 EWAGE # VILLAGE ASSESSOR'S MAP & LOTa? a S-Z INSTALLER'S NAME.6z PHONE NO. SEPTIC TANK CAPACITY ,";,LEACHING FACILITY:(type) - (size) °-NO. OF BEDROOMS I{ PRIVATE WELL PUBLIC WATER BUILDER-OR OWNER d DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No p 6"l9b Ll r+ 1 *x s µ1 No. �✓ Fee '�O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitation for Nsposal 6pStem Construction Permit Application for a Permit to Construct( ) Repair(-*)�Upgrade( ) Abandon(,X' ❑Complete System ZIndividual Components Location Address or Lot No. CL t� �r9�G 3" 'A�e Owner's Name,Address,and Tel.No.jt:f�-27Sa V f,`� Assessor's Map/Parcel Installer's Name,Address,and Tel. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size ..2r=4,Ac be e3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date 1 Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) eng"�� Ea "ve Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed �"�—>/ ._ Date�CC" Application Approved by /l 114 2 Date _ Application Disapproved by Date for the following reasons Permit No. �9_6 3 — 2j , ` Date Issued C� No. d ( V✓ Fee ' V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yew PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4plicatlon for Disposal Epstein (Construction Permit Application for a Permit to Construct( ) Repair Upgrade( )y Abandon(,,4' ❑Complete System C Individual Components Location Address or Lot No. a k-) 1jc v=�cS2 GJ" �P�-� Owner's Name,Address,and Tel.No. G,Ze Assessor's Map/Parcel Installer's Name,Address,and Tel. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 ( Lot Size sff-, c CS sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. - 1 Description of Soil t Nature of Repairs or Alterations(Answer when applicable) ` r S ' Date last inspected: 6 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date _ Application Approved by c--)'yl &1 ,��1 Z f K--S Date Application Disapproved by Date for the following reasons Permit No. 3 -2> � � Date Issued ------------------------------------_--------- i TIC E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned(✓�by ��,c, , \�cr ��.c.`a � �� at �2( l, 4�c�c�Qa'l- tA��.�•1�y>c�,�;, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer���cSZ.� c�v-.rC e t, _ ti Designer. #bedrooms ?, J Approved deessiggnn flow 7 gpd The issuance of this e t s'a)ll not be construed as a guarantee that the system Zvi fuhction aasr,desig ed C IJ Date / �J Ins ector l� P --------------------- ----------- ------------------------- -------------------------------------- --------------------------------- No. d1,7 Fee /()0, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal QPpstem Construction 3Pefmit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon(✓) System located at �'� �c c_�� '- A-u �r`1 V KA tA A" and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must fbe completed within three years of the date of this permit. �" Date (} / Approved by Ph /J, No. U t? 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS YeS ZippYication for Vsposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components Location Address or Lot No. rf l 5rk (Q(0 Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel l-vIkWl< P474ldt4 P 3O ®l S =3 cry Tr.- P- 1V Ec��T�1i NA O �- Installer's Name,Address,and Tel.No. S-M-W77-2211 Designer's Name,Address,and Tel.No. 0 �4oleo -t �cLj- NA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed_ /� Date 9'/� a`® 3 Application Approved by'/�L✓�� �1.��. Date /-7" a� Application Disapproved by Date for the following reasons Permit No. Date Issued ------------ - - — M -----_-------------- ------- - (� J t✓ R» _ No. �U�� Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for bisposar *pBtrm Construrtion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components Location Address or Lot No. r!j S&-Ae RC) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 3o Q 1 S H *> is =3 0L Ta &jaLQ.JTL'J_MA O Installer's Name,Address,and Tel.No. S'M-4-r?-22 71 Designer's Name,Address,and Tel.No. C40�f6 � �T&WOU� L� N1A k - 6-9 bW tn.C1 si- P&G- Type of.Building: Dwelling No.of Bedrooms Lot Size -?y-OS{ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) 5 Other Fixtures Design Flow(min.required) gpd Design flow provided gpd F 1. 1plan x Date Number of sheets Revision Date x Title Size of Septic Tank Type of S.A.S. Description of Soil `Nature of Repairs or Alterations(Answer when applicable) • a. Date last inspected: Agreement:The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has.been issued by this Board of Health. - Signed Date 9-( 0 t3 p Application Approved by �'� Date / - /7 Application Disapproved by Date for the following reasons `` Permit No. Date Issued TILE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(k)by�'QdlW 1D6 GXr& k,<S� at �� 5'� d(>�(� �,� l-(-�iL4A42i S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N ij D I � 1- :Y-'Ated Installer61,c�ln� �� � (�-�•• Designer #bedrooms Approved design flow ! gpd The issuance of this permit shall not be/cp nstrued as a guarantee that the system willll" ncctioonn,as,dessi{gned: / / Date �/ � {/ Inspector '' ljl 'J! /I _�-% t ,?° ,'l LV Mm() -------- ----------------------------------------- -. - - t/ No. . U (�j - ,(�- t Fee �• THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 33isposal :�)Pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by 217 Scudder Ave Floor Plan 1st Floor Coll*' _ g��Gw 1 1 1 Second Floor � 1 ( ((!!�� I �1'r , � �41� 1 In b r��, (Ix/v� A i l!'� r �;,� �J 7 ,` . �,.� 4,� -0 r .� �•. `i {� k Town of Barnstable IME Regulatory Services Thomas F. Geiler,Director MB Building Division 163 Thomas Perry,Building Commissioner En 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-790-6230 August 2, 2013 Attorney Leslie-Ann Morse 477 Old Kings Highway Yarmouth Port, MA 02675 RE: 217 Scudder Ave, Hyannis Dear Attorney Morse, I have reviewed the documentation that you have supplied to this office on July 29, 2013. From this documentation, it appears that this property is a pre-existing non-conforming use. Sincerely, Thomas Perry, CBO Building Commissioner k I } A . LESLIE-ANN MORSE Attorney at Law 477 Old Kings Highway Yarmouth Port, MA 02675 Tel (508) 375-9080 Fax (508) 375-6303 July 26, 2013 Tom Perry Building Commissioner Town of Barnstable 200 Main Street Hyannis, MA 02601 N RE: 217 Scudder Ave. Dear Mr. Perry: 3 Please be informed that this office represents John and Norrine Czekanski who are the current owners of 217 Scudder Ave. The property is shown as Lot 80 on the Barnstable Assessors' Map 289. It is also shown as Lot 11 on Barnstable Plan Book 38, Page 91. In addition the house number for the property has changed over the years and it was formerly known as 151 Scudder Ave. The property is improved with a 3-bedroom house and a detached 2 car garage the second floor of which is a one-bedroom apartment. It has recently come to my clients' attention that there was a question regarding the legality of the apartment. I have spoken to the Barnstable Zoning,Enforcement Officer, Robin Anderson, and she deferred the matter to you. On behalf of my clients, I have researched the records of the Town of Barnstable and find the following. At some point in the past, the Assessors put on microfiche a set of Field Cards containing information from the late 1940's and early 1950's. I am informed that the microfiche LL is very old and brittle. The machine used to view the-cards is also very old and no longer able to print copies of the cards. The Assessing Office was able to transcribe the information and it is attached hereto as Exhibit A. The information shows a 1950 listing "DWELLING HSE" indicating that the property had been improved by a home. The 1951 information states "DWELLING HSE" and "DWELLING GAR", which would certainly indicate to me that there was now a garage on the property part of which was being used as a dwelling. (Exhibit A) In addition there are Assessors Field Cards from the mid 1970's. There are 2 field Cards for 151 Scudder Ave. (Exhibits B, C) The first for the house and the second for the garage which clearly �Ik . k- ne states 2„d floor apartment. I have also enclosed a record from the Assessor's Office dated from the 1980's which is labeled GARAGE APT. with a diagram of the Apartment. (Exhibit D) Additionally, I have enclosed aerials from the Barnstable G.I.S. Office. The first.aerial was taken ! in 1952 is rather fuzzy but clearly show a substantial structure where the garage is located. The i garage with its second floor dormers is clearly shown in the 1968. aerial. (See Exhibits E, F) It appears most likely that the garage and apartment were constructed somewhere between 1947 and 1950 as the Assessors records are always a year or two behind. It should be noted that the Assessing records themselves state an age of 1947. ! I have also researched the records of the Barnstable Town Clerk relative to the historic zoning in the Town. I have found a Zoning Map dated June 1950. This Map shows that the village of j Hyannis including the Scudder Ave. area was under the original zoning for the town passed in 1929. There is a copy of the 1929 zoning bylaws in the Town Clerk. I have reviewed the same and find no prohibition against having two dwellings on the same property. There was also an updated 1948 copy of the By-laws in the Town Clerks file.,This Bylaw also does not contain any prohibition against having two dwelling on a single lot. I would request a letter from you confirming the apartment on the 2nd floor of the garage as a legal pre-existing non-conforming use. If you have any questions or would like to discuss this matter further please do not hesitate to I' contact me at 508-375-9080. Yours very truly, Leslie-Ann Morse cc: John and Norinne Czekanski i I i J 1 J 6 PRI:CING�k n sr:�".. ._ ct'. '�!9 ;•!''i 4 ,p--. .,. �..a Itt��-_ .._: LAND COST COST .. PURCH. DATE 19& / y .IPW`ailw_•a A r PURCH. PRICE �� ✓v�Sw t JJ�1 n,lY l .�i�j�•?•%r'r'� � ' gu.'yga• iT� R4i1� �:r, ao(( k RENT CJ.eG r 4i k':'u:.:✓ * "'il 12— y L y .� c� ! ���:s y�r+a���sEs fa)�-���,r?-.�- • f ..�'�//a[: G .. IN i ���` � !�.,• �' +�'!t�!�8e�a�.�--+er,o-. Heel /� L J - � :. -x .�,Yq';:: < 1.�+1 -d i�•I ys a�^ae'1�Z .0 Aplo Ht.Unll � � %Z:� 2 i 'L r! ,-» '� ',. 'i r �� X a�..� � s�fll-fI B,Walla,e _ Flrepfaco 7�"' � ..•���'} .. --- Plumbing jr S 0I S Flh --..__.. . . Tiling f10 1,h3 ��. .a �. �Te�eII U�i�LIFI ' ` ft!►- l> Y. a. Shower 4t1 �, Tub Ares Total - COMPUTATIONS s t e1W ennfpr t l / d S.F. vP 5 ' n 4 t}�ai�,it Wr y�y Y= S.F. �\N MoVL V C00 O -• :.t'L, . ,.•..fir' S.F. - -�'-v-j tic, .. f1 D O t Y }�f u. j t. gat,T..- a S.F. _9, O OUTBUILDINGS �Irtxl7F_ Eetit�c `,.. S.F. 1 213 4 516 7 8 9 10 1 2 3 4 5 6 7 8,9 10 MEASURE[ . _FlREPLgC'ES S.F. Pier Found. Floor 6 14 wflrePlace�Sleck1.• Well Found. 0.H.Door LISTED vi Flrep(ece.lt4 '; S g• Rolf Roofing � � goo.Sd g�r $ .LIGHTING o lect ' Dhle.Sdg. Shingle Roof y- Shingle Walls _ Plumbing DATE ROOMS .y,r Convent 8lk. Electric • '" Bsmt.'., s13 TOTAL . Brick Int.Finish PRICED T— I '+S [� �1nd,� %j 3rd FACTOR (.[ s Lai ` '•' REPLACEMENT Qg =f- D UPANC.Y:ffi""^ CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE fund.Dep. ACTUAL VAL. - i —717` - 1 p� a a TOTAL i e " .:n'c• _t•...A I++.:�'aG•..�M '..�i.� .y-..:.�_ ..,y1:y.+m[a,•^'.an:', 'm�' DESCRIPTIVE INFORMATION :,�PROPERTY ADDRESS �� 15 1 S�.U U U L f. A V E H YA NN . ;PD LEVEL ` La: (: 'REET f A V E G `1 '� h i P :F A f G A S S E P T + - --------- , ctL ... - ��' � I HIT I LAND.DATA& COMPUTATIONS I r. �I ACTUAL EFFECTIVE EFFECTIVE DEPTH AC I UAL. EFFECT IVE INFLUENCE LOT If I{ FnnNTAGE. FFI1 MI AGF DEPTH FACIOF UrJIr PRICE 11NITPHICE fACIOR VALUE I JT i.vU LA Pt) rN TRy I I £' i I t*+ I >T �a it Wq i J 1 )7 ' ! I fi 28 A �( -3, 1 1 , I )TAL ACRES f j BOSS LAND +, :�,y,.r:y;:.-• r, a 1 I I�.x a, . ',}•,y_�;;I•�y+t•�' �`. •-�.. :' 7�•;:�,4 TOTALLAND VALUE'!'n' - 7 DWELLING DATA&COMPUTATIONS I I P D.LIVJNGUNITS Ofl STORY•HEIGHT/ATTIC ► — L. S I Y L GROUND FLOOR AREA• b 7 2 S F +—� -- 2 4 — --+ F )TAL R TER OOMS ;(-;• ;0 EXIOR WALLS ":;, FRAME :DROOMS. i '' V1 ADJUSTED BASE ' 38920 ADCU26R241)28L24H 1MILY ROOMS. '•, U BASEMENT ' EAT:SYSTEM/FUEL,` H W AT/OIL 'HEAT&A/C'•;,.:'r BASIC 0 4THROOMS. FULL 1 PLUMBING 5 FIXTURES 0 ^~M t DDITIONAL'FIXTURES 0 EXTERIOR TRIM r' rrfib r REC ROOM FIN BSMT LIVING AREA I "t' 1NBFPNVOOD BURNER ICENYRALI:' W B=0/0 9 M T=1/ 1 ,C- 1300 " BASEMENT GARAGEjlF I` )TALS.F.LIVING AREA 1176 4 UNFIN AREA P NARRATIVE rtrtWW _ SUBTOTAL• {, L ?lo ENTRANCE CODE•:• CAL .AR BUILT" 1947 GRADE., i:' C— = •9 2 —3 20 0 :.ADDITIONS t =,_•., f✓ PP ".•,REMODELED.-.'c Car-DFACTOR+ ..':.! 't.,.`. `� ID ' LLr: ,'1..;:.. 2 + a3'7r-JIREAC': L15T; Ir: . .:. ?1li.i:i,::�r; :a 11!SICAL.CONDITION ',AV(=tiAG E 'RCN•• ".'� '•`' 37000 .•`• ,I >U + FR DEPRECIATION., F COST •YAL 2 F.:: .. ::i 1 1 m TOTAL DWELLING VALUE:.•„ `; >* s MKT—EST 2. : OTHER BUILDINGS&YARD ;: ' MKT YAL'.- 2 ,l:d{I•i.;'•+I'f'••• A t :,' .,: "''arl:JL•1 . SN TYPE CITY CSN , YR ''P SIZE AREA. GRO RATE CONb MOD CD flCN v. 1'. F p r TOWN OF BARNSTABLE; Ftl , TOTAL; i' FISCAL 1983 f ... \\ ?'.. r. •wI rin S•. ALES DATA ,+T+�•=ty�`�IY�� - _ �..,, iltSiFitil:.-V[.LIt:.,. ...:h•.. T, ;i`•�` VALUES, ys,� OLD„I '• APPRAISAL: CURRENT ASSMT t ®R TOTAL OB&Y .'0 LAND ^p 2220.0BLDG "ate_ 0 <K1EN7 TOTAL . 0 22200 I ` COMMONWEALTH. OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICIAL INSPECTION FORM—TTI�.E.S. . NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: yA�'..cr•s Owner's Name: Owner's Address; i 7 40L A Date Of tspection' C S Name of Inspector.(please priatk"y.✓ Company Name: Mailing Address. -------- Telephone Number. CERTIFICATION STATEMENT' I certify that I have ers below is tru P �Y���sewage disposal system�this address and that the information reported e,accurate and complete as of the time of the inspection.The inspection wasp t the information based on reported uaiaiag and experience in the proper fimcdo�n and maintenance.pf on sitemy approved system inspector pus so at to Section IS 340 of Title S 1Q sewage�Sa ems.I (3 C�1�000�. Thesyst system:am a DEP — t'a ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Farts Inspectorts Signa Date: The system inspector shall submit a copy of this inspection DES within 30 days of completing� ��systern�°rt to thr ApgrovIDg Authority(Board of Health or 9Pd ,the inspector and the is a sisated nt has a design flow of 10,C00 or systern owner shaA submit the report to the DEP.The original should be seat to the system owner and copies sent to the buyer, regions!office of the authority. yer, if applicable,and the approving Notes and Comments ""This report only desen'bes conditions at the time of.inspection time-This n and Hader the.conditioas of use at that inspection dues not address how the system will per�nrm is the tatture under the same or different conditions of use, Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS 'SURSMACESEWAGEDISPOSALSY MUNSPEMONFORM PART A C'ERTMCAnTION(cantianed) Property Address:2. ! 7 G y .s Owner. /'16Z ,v ,✓ Date of Insptttion: eS Inspection Summary: Check AB CD or E fALWAYS complete all of Secfi=D- A. System es: I have not fotmd any udvrmation which indicates that any of the fatlm a criteria described in 310 CMR 15303 or in 310 CMR 15304 exist.Any lafimz criteria not evaluated are indicated below. Comments B. System Conditionally Passes: One or more system as descn'bed n the"Conditional Pass"section need to be replaced or repaired.The system,upon 1 of the replacement ortepair,as approved by the Board of Health,will pass. Ahswer yes,no for the following statements If"not determined"please explain. The c tank is and over 20 years old*or the septic tank(wbether metal.or not)is structurally unsound, its hdMradon or atfilttadm ar tank failma is immfmnt System wt71 pass.inSpCGlan i€the existing tank rep with a complykj septic tank as approved by The Bond of leaftb. =A metal pass inspection if it is sM=tmally sound,not leaking and if a Certificate of Compliance indicatingthat th is less than 20 years old is available. ND explain: Observation ofsewage or static in the distrRratian hmr-doe to brok=or- obstructed pipes)or.dae m settled or, dis>n bcm.System will pass.inspectim if(with approval of Board of H th} bnalcen s} laced .od. b is]err�sd ar.rrglaced. ND explain: The system required purn more than 4 times a year due to.brokm of obstructed pipe(s).The system will pass inspection if(with f the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: P,9ge 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. -v Date of Inspection: 7 C Further Evaluation is Required by the Board of Health: Canditiom exist which require Rather mifinitio of Health in order to determine if the system is failing to protect public health,safety or the tm:ent L System will pass unless of A es in accordaacr with 310 CN R 15.303(I)(b)that the system Is not g is a which Will protect public health,safety and the eavironmeub _ Cesspool or is 50 feet of a surface water _ Cesspool or withist 50 feet of a bordering vegetated wetland or a salt marsh .2. System will&H unless the Board of Health.(and Public Water Supplier,If any)determines that the system is functioning in a manner that protects the pub health,safety and environment: _ The system has a septic k and soil absorpti system(SAS)and the SAS is within 100 feet of a ;,;face water supply or tribt war supply. The system has a septic tank and AS an the SAS is w ae-1 of a public water supply. The system has a septic tank and S and the SAS is within 50 feet of a private water supply welL The system has a septic tank and and the SAS is less than 100 feet but 50 feet or more frorti a private water supply wells'.Metb to determine distance "This system passes if the well analysis,performed at a DEP certified laboratory,for co&form ba,-xda and volatile organic unds indicates that the well is free from pollution from fiat facility and the presence of ammonia and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trig, copy of the analysis mast be attached to this form. 3. Other. Page 4 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALS Y 41NSPECTIONFORM PART A CER31FICATION(confinuedy Property Address:2/7 Owner. sd•✓ Date of Inspection: Z., i D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for III inspections: Yes No of sewage into fac7ity or system component due to overloaded or clogged SAS or cesspool or pending of effluent to the surface of the ground or surface-waters due to an overioadcd or //vlogged SAS or cesspool _ �tadc liquid level In the distribution box above outlet invmrdecto im overloaded or clogged SAS or 'AesspooI depth in cesspool is less than ti"below invert ormnilable-volmae is less tim%day flow _ I more than 4 lanes in the Iasi yearNQMdue to clogged or obstructed pipes)-Number times pumped portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy Is withal 100 feerof a surface water supply or tributary to a surface , Supply. 1 An :portion of a cesspool or pry iswithin a Zone i ofa public we1L 7 portion of a cesspool or privy is within 50 feet of a private water supply:well. Any portion ofa cesspool or privy is iewthaur 100 feet but greater than 30 feet from a private water supply well with no a=ptable water-qualityaualysis.[This system passes if the well water analysis, performed at a DEP eerdfled laboratus for colifwu bacteria,and volatile organic compoaads indicatts that the welf is free from pollution from that bellity and the gressence.of ammonia nitrogen and nitrate nitrogen is equal to or less tlxaS ply provkIaLthat no other failure criteria are trL0)-'Mkin3l0CMR-l'5.303,the:efix ered.A copy of the aaalysismwt brstbchetl.tu}this•formas.1 affe! system�I-bave determined that one or more ofthe above failure�ia exist as rthe-system ice•The system awner.should contact the Board of Health to deortatiae whrarwM benecessary to correct the failure. F- Latp Systems: f To be considered a large system t e�mrwi *sa wea factlity_wi&A desiga:Dow of 10,000 gpd to 15,000 apd- Yea moat indicate eith or 'to each of thtfoll (The fo110w1IIg Bpply to II to the aria above) yes no — the system 400 feet of a sunface drag water supply —— the system 200 feet of a tn'nnary to a sw:B=drinking water supply — _ the system is located is a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a ripped Zone II ofa public water supply well If you have a wmmd'W to arty question in Section E the system is considered a significant thrcat,or answered 'des"in Section D ebovelhe large system has-failed,Mm owner or opmmtar of any large system considered a significUnt threat under-Section E or Wed under Section D shall upgrade the system in accordance with 310 CMR 15304.The system owner should contact the appropriate regional office of the Department. cadge 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addresr.oL ll Y AH.v is Owner:^2- 1710 W s a,%0 Date of Inspection: S _ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: 2Y /No Pumping iafarmatioa was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? ZHave Has the system received normal flows in the previous two week period? large volumes of water been introduced to the system recently or as part of this inspection? ZWere as built plans of the system obtained and examined?(If they were not available note as N/A) zZ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system wmponents,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 bales 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 e ? ��system The size and location of the Soil Absorption System(SAS)on the site has been determined based on: :71-to f , Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related io Part C is at issue approximation of distance is unacceptable)(310 CMR 15302(3)(b)J page 6 of 11 0FFIC7A IlNSPEC'PION FORM—NOT FOR VOLUNTARI ASSESSMENTS SUBSUItFAtE:SEWAGE-DISPOSA SYSTElyi MPEL'IT FORM- PART-C SYSIMM INFORMATION Property Addre=2 6' �c rt�!/E Owner. • /'y!L74 .v r .✓ Date of Inspeetloa: 157 aJI- FLOW COMMONS RESIDENTIAL Number of bedrooms(design Number of bedrooms(awralx DESIGN flaw based on 310 miM(for xample:110 gpd x#•of bedmams): �" Number of cur, tesideow Does residence have a garbage grinder(yes or no):,40 Is laundry on a separate sewage system or nor�1f yes sepatateinpection required] Laundry system inspected or no): a Seasonal use:(yes ornoja, s Water meter res&gM if available(last 2 years usage(gpd)): sump Pump(yes orno)r.Ako Last date of occupancy: ! i COMMERCIALMMUSTRUL Type of establishment Design flow(based13107011 203r Basis of design flosgftetc. Grease trap presenIndustrial waste bont ornor Non-sanitary waste Title 5 system(yes or no):watermeterLast date of occup OTHER(describe)- GENERAL INFOR]1UTION Pumping Records Son=of iiiformatiow � WA- Was system pumped"as part of the inspection(yes orno)r. If yes,volume pumped_,gallons—Now-%w quantity pumped•de:==*d?- Reason for pumping: f F�SYSTEI�' . _Septic tank,dssaibuflon box;soil absarpaan system' _SWC_cesspoo.l _Oftflow•cesspoor —Shared snteur(rn m-no)(ifM attach jumious itispectimi jem if any)- _ technology.Atmckwcopy ofthe caarent operation and maintenance contract(to be obt bed-from system owner). Tight tank, __,_Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed Cif known)and source of information: Were sewage.odors detected when arriving at the site(yes or noW P=7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSI M INSPECTION FORM PART C SYSTEM INFORMATION(conduDed) Pmpmty Add,ess:2 Owner:/7 A .C,v o 0 Este of Inspecdow i o BUELDING SEWER(]ocafls on site plea) Depth below grade: - Materials of rAnsaucd : cat tract PVC other(explai#. Distance from private wafter supply well or suction line: Comments(on condition of join%venting.evidence of leakage,etc.): SE MC TANK: (Iocame on site plea) l Depth below wade: N42=r al of not utexiotz: _metal fiberglass_polyethylene otirct(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy o' Certificale) Dimensi ons:T S/ X S X s Sludge depth:_ ) " Distance from top of sludge to bottom of outlet tee or baffle: 0 _ -Serm thici 6-o* Distance from top of scam to top of outlet;tee or baffle: Distance from bottom of scrum to bottom of outlet tee or baffle: HOW were dimensions detmmhm'd: Comments(on pumping recom atioeos,inlet and outlet tee or bafffe canditior,structural integrity,liquid le:,els as related to ou tin evidence of leakage.etc.): d GRF.4SE TRAP:(locate on site plan) r Depth below.grade:_ 1,,.. ' MaLerial of motion: cone y _polyethylene_otber (explain): Scum thiclmess: Distance from top o scum top et tee or baffle: Distance from o bottorn of ontlet.tee or baffle: Date of last pampin C.ertts(on puautp' recommendations,islet and outlet tee or baffle condition,structural integrity,liquid le"Is as related to oud evidence ofleakage,etc.): Page a of 11 OFFICIAL INSPECTION FORM—NOT FOR V,UNTA.RY ASSESSMENT'S SUBSMACE SMAGE DISPOSAL SY'STI!'M NSPEMON FORM' PART C STEM EOMMAMON OMftued) Prue►Addre= ! nQ�v Ownerr. Dstn of Inspecoom o 'nG&T or FOLDING TANK: (teak must pumped st lime of on site pIaa) Depth below grade Material of�sxdoa: metal fiberglass_po�y� ofl=(explain). J cap r Design Floor_ ous[day Alarm present of no _ A laral ICYClrInV"Orkin$.atder(yes of no) Date of Commeoes(condition of alarm.and float switches,etc - DI�"1RIMTt`ION BOAC: (ifpreseat rrmst be opened)Oocate on site phm Depth of liquid level above oudet invert Cents(note if boot is level and distn udon to mWea=pMl,'arry evidence of solids carryover,;my evidence of l=kage into or out of b, etc. : ir d- Lt vF / s' - c Lc �4I'L s ✓o 16 0T•( 1- PUMP � n on site P �s in k or no Alaims in worlQag es } Comm"(note pomp chamber*Ton 6f'pusd c )� Pug--=l 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address- / JG �l Q &,� Owner. .✓ .✓ Date of Iaspeet'rm 6 i7 SITE EXAM Slcpa L e A'a Surface water.ram¢Y Chxk=Dar j)2�' Shallow wells ,t/o-✓E Estimated depth to gtrnmd water ? feet IS—,2 Please incricate(check)all methods used to determine the high ground water elevation: Obtained from system desip plans an record-If checked,date of design plan reviewed: Observed site(abutting propc3 ylobservation hole within 150 feet of SAS) _71Checked with local Board of Health-explain: G W .S /yi A!• -r /e H,, Checked with local cccavau rs,mstaIle.s-(attach documentation) .Accessed USGS database-e3cplaftr You must describe haw you established the high ground water elevation: dz e .",R G(/.A i 42 sum, v 6 y 1117AilS 4 ! D Q 4-0, "a sn/a`yA '�.✓ o ' A[3e v r Lt/A i a'e L �c- / . - j T✓ %p 3??o • LEA✓-wd S • • Page 10 of I 1 OMC ALMSPF,[' ON FORM—NOT FOR v(']LtJN1ARYASSESShIENTS SUBSURFACE SKWAGE DISPO FORM PART-C SYSTEWINFORMATION(co -- Property Address Owner. Date of Inspection; . SKETCH OF SEWAGE DISPOSAL SYSTEM' Provide a sketch ofthe sewage sIisposal system including ties to arleasttwo Famanearreference landmarks or benchmarla.Locate alfwelr withmA00 feet Locate whempublic watersupp4-enters the-building. Avg G fj G . 0 I3 = a o,d- a. o Page 9 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS AL SYS•I'E1VI INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: Owner.'' A .7-e .v �-,,✓ Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): on s;tiplaneze2vation not required) If SAS not located explain why.. Type leaching m number: leachinrchambers,nttmber lcachfuggalleries,number. leachting trenches,munber,length: leaching•5elckuumber,dimensions-. vverfloarcesspool,number it ovativelakernadw system•Typehww of technology. Comments(note-condition•ofsoil,•sigurofhydraulicfulw•e,level of ndin etc.): po g,damp soil,condition of vegetation, t T/[/ — sr i i CESSPOOLS: (cesspool must be as part of in_cpection)(locate on site plan) Number and won: Depth—top of liquid to inlet inv Depth of so Depth Layer: Dim ons of oL M of Indi dvtaux inflow(yes or no C is(note condition of sotl,signs ofhydrauGc fadttre,level of pondmg,condition of vegetation,etc_): PRIVY' (locate on site plan} Materials of c ction:- `Dimensions: Depth of soli ; Comments(no ition of soil,signs of lrydraulic fai lmr,level of ponding,condition of vegetation,etc.): FILE # K 5473 CENSUS TRACT # 125 CLIENT: Kelton Johnson DEED BOOK 4793 PAGE 135 OWNER : Kelton Johnson PLAN BOOK 38 PAGE 91 LOT APPLICANT: same ASSESSORS PLAN PLOT MORTGAGE INSPECTION PLAN of LAND I N B A R N S T A B L E SCALE: 1"= 40 APRIL 15, 1993 LOT 2.1 L oT zo loo.op' L.CS�I I GAR• 129OO±S,F. LC)T. 10 #151 11�Zs�rY 129.2.E PAvED I29.Z7' I oo.00' SCUDDER AVEWUE I CERTIFY TO ATTORNEY GERALD SHUGRUE, UNIBANK, AND ITS TITLE INSURANCE CO, , THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS EXCEPT AS SHOWN AND THA THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION . THE LOCATION OF DWELLING AS SHOWN IS IN '�.�=..1" , COMPLIANCE WITH THE LOCAL ZONING BY—LAWS ``'"� ;'K�t, ',r WITH RESPECT TO HORIZONTAL DIMENSIONAL 47 REQUIREMENTS. �Jrr�tax .Fl :� r x ► THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL FLOOD. HAZARD ZONE AS 44...'''�c DELI NEATED ON A MAP ..OF COMM(IN I;TY #250001 —0006 DATED 7/2/92 BY THE F. I .A. Land Surveyors Civil Engineers S� V c q Z 3 3 (®lae �ortonPna �$urveg (go., �nr. q 2 00 �— ° 172 pilliumt. I-xA _ ,tt -`t, vv� efn eDforD, 102740 GENERAL NOTES: (1) The declarations made above are Sn the basis of my knowledge, information, and belief as the result of a mortgage plot plan tape survey inspection made to the normal-standard of care of registered land surveyors practicing in Massachusetts. (2) Declarations are made to the above named client only as of this date. (3) This plan was not made for recording purposes, for use in preparing deed descriptions or for con— structions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may A be accomplished only by an accurate instrument survey. �al _C d�P q Q S 1 q '7 0 r" CD I •I dB"� L O _ a. Ln out CO Pbsta $ ru �Q Certified Fete, O cn 1-3ReturnReceipt Fe - bP Here k N C3 (Endorsement Requir 7% 1Here Restricted Delivery Fee 2b J 0 (Endorsement Required) r� '7 O Total Postage&Fees �. r9 ru John Czekanski�' "217 Scudder Ave: Hyannis, MA 02601 Certified Mail Provides: a A mailing receipt a A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,at Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt^service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the- fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for- a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. — ;�' - a For an additional fee, delivery may be restricted to the addressee 'or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 +w CO UNITED SLATES rUSTAL SERV CE First-Class Mail Postage&Fees Paid cs; USPS Permit No.G-10 ki CSendet: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division 200'Main Street Hyannis, MA 02601 ,SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY s Complete items 1,2,and 3.Also complete A.,Si a re item 4 if Restricted Delivery is desired. Agent X ©° . ■ Print your name and address on the reverse A88ressee so that we can return the card to you. B. Received by(Pri Name) C.D /1 atp of�livery ■ Attach this card to the back of the mailpiece, N or on the front if space permits. D. Is delivery address different from item 1? ❑Yes' 1. Article Addressed to: If YES,enter delivery address below: ❑No 1 John Czekanski 2W Scudder Ave. 3. Servic Type Hyannis, MA 02601 ertifiedMail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service labe✓J 7 012 1010 0000 2850 9378 PS Form 3811,February 2004 Domestic Return Receipt 102595.02,M-1 0 nstable �99 Town of Barnstable Bar Regulatory Services Department • IARNSTASIE 9 MASS. i639. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2850 9378 Jun 26, 2013 John Czekanski 217 Scudder Ave. Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 217 Scudder Ave, Hyannis, MA was last inspected on 5/31/2013, by Patrick T. Sullivan, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines • of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic system is in hydraulic failure. • Leaching pit is under driveway. You are ordered to do one of the following, within two (2) years) from the date you receive this notification: a.) replace the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component, or by b.) replace the septic system component with an H-20 component beneath the parking area or driveway, and properly abandoning the discovered H-10 component, or'by c.) relocating the parking area or driveway in such a way that no vehicle will have access or the ability to drive over the existing H-10 septic system component. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. Z ER OF TH BOARD OF HEALTH cKean,R.S., Agent of the Board of Health Q:\SEPTIC\conditionally passed\217 Scudder Ave HY Jun 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22084 Ix �3 • Logged In As: Parcel Detail Tuesday,June 25 2013 Parcel Lookup Parcel Info Parcel ID 289-080 _ Developer!LOT 11 ' Lots Location 1217 SCUDDER AVENUE Pri Frontage 100 T� Sec Road Sec 1 Frontage Village HYANNIS ' Fire DistrictiHY N S Town sewer exists at this address NO -- —I Road Index 1440 f Asbuilt Septic Scan: Interactive , 2890801 Map ''MI'�� Owner Info Owner ICZEKANSKI,JOHN A& NORINNE R I Co-Owner Streets 217 SCUDDER AVENUE ( Street2 City HYANNIS ( State IMA Zip02601 Country Land Info Acres 10.29 j use ISing� le Fam MDL-01 , Zoning!RB Nghbd 0106 Topography CLevel Road Paved Utilities I Public Water,Gas,Septic —) Location Rear Location Construction Info Building 1 of 1 Year Roof Ext led Shin !Woo Built 11947 Struct GGable/Hip wall g Living 1732 Roof=AS h/F GIs/Cm AC!None . Area�_. Cover I p J Type I1A tub 1 Int Bed styleCape Cod wall 3Plaste � Roo Bedrooms red Int Bath i Model Residential Hardwood 2 Full Floor r_ Rooms 4 1`' Tq Grade Average Heat Hot Water Totalr,�i Type Rooms { — Heat L— _ Found stories 11 1/2 Stories Filel iGas atio-iConc. Block Gross Area 3387 , Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22084 6/25/2013 IAAV r Commonwealth of Massachusetts Title 5 Official Inspection Form cop�'Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis _MA 02601 May 31, 2013 required for every Y 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 filling comp A. General Information � !� on the computer, 4� `//7 use only the tab 1. Inspector: �q key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating �y Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority June 7, 2013 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. t5ins•3l13 Title 5 Official Inff,. o n:Subsurface sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is required for every Y H annis MA 02601 May 31, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is a single, overfull cesspool located under the driveway. 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 complet' n of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no"or"not determined" , N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years * or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or xfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan Is less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below): t5ins•3/13 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y Y page. Cityrrown 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 ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled r 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 /reheoe d by th 'Board of Health: ❑ Conditions exist which rrthe evaluation by the Board of Health in order to determine if the system is failing to ub,* health, safety or the environment. 1. System will pass u rd of Health determines in accordance with 310 CMR 15.303(1)(b)that the snot functioning in a manner which will protect public health, safety and the environ❑ Cesspool or priin 50 feet of a surface water ❑ Cesspool or priin 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 .' 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is required for every y H annis MA 02601 May 31, 2013 page. Cityrrown 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 th SAS is within a Zone 1 of a public water supply. [IThe system has a septic tank and SAS and t e SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and t 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 a lysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n 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 1/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is May Hyannis MA 02601 required for every y y 31, 2013 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you /qe ate either"y, }"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ th is wit In 400 feet of a surface drinking water supply ❑ ❑ the is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ theis located in a nitrogen sensitive area(Interim Wellhead Protection ArA)or a mapped Zone 11 of a public water supply well If you have answered"yy question in Section E the system is considered a significant threat, or answered "yes" in Sebove the large system has failed. The owner or operator of any large system considered a sighreat 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May required for every y y 31, 2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® 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 l Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 GPD t5ins-3/13 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every Y Y page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d From main house 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM/Title Gallons per day(gpd) Basis of design flow(seats/pe Grease trap present? ❑ Yes ❑ No Industrial waste holding tank p ❑ Yes ❑ No Non-sanitary waste discharge ❑ Yes ❑ No Water meter readings, if avail t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageD' -Disposal System Form Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May required for every Y y 31, 2013 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: Owners records: Pumped 3 years ago. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Inspection and overfull 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-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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May required for every y y 31, 2013 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: System approx. 40+ years old. No info available at Board of Health. No mention of cesspool in previous inspection in 2005. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ❑ 40 PVC orangeburg ® 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 C ificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3113 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is May Hyannis MA 02601 required for every Y y 31, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of o let tee or baffle How were dimensions determined? Comments (on pumping recommenda 'ons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inve , evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal dfiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to op of out tee or baffle Distance from bottom of s um 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 ,..�` 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owners Name information is Hyannis MA 02601 May 31, 2013 required for every y Y page. CitylTown 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(conditio 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution/totletsequal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pumZamber, ion 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 217 Scudder Ave., Apartment _ Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31 2013 required for every _Y Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 2' over 8" Depth of solids layer Depth of scum layer 6" Dimensions of cesspool 3.5'X 4.5' Materials of construction Concrete block 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every _Y Y page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Comments note condition of soil, signs of hydraulic failure level of ondin condition of vegetation, ( 9 Y P 9. etc.): System overfull and in failure at time of inspection. H-10 cover is to grade in driveway. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition /s:ignsraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is required for every HyannisY MA 02601 May 31, 2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o �A co i = I J t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts RE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•' 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is required for every Hyannis MA 02601 May 31, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: www.terraserver.com ma.water.usgs.gov You must describe how you established the high ground water elevation: Main house Title V Report. No inflow of ground water after pumping. Base of main house leach pit lower than base of cesspool. 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 217 Scudder Ave., Apartment Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May required for every Y y 31, 2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Copy Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May required for every Y y 31, 2013 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 forms A. General Information (1 on the computer, U use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �_z l June 7, 2013 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Propery has detached garage with a one bedroom apartment. Not connected to this septic system. See report for"217 Scudder Ave., Apartment" 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" N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration ore tltration or tank failure is imminent. System will pass inspection if the existing tank is replaced w a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti n if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank i less than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): e I t5ins-3/13 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31 2013 required for every Y y , 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 igh static water level in the distribution box due to broken or obstructed pipe(s) or due to a bro en, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is levele 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 Req/purbli Board of Health: ❑ Conditions exist which requevaluation by the Board of Health in order to determine if the system is failing to protealth, safety or the environment. 1. System will pass unlef Health determines in accordance with 310 CMR 15.303(1)(b)that the systunctioning in a manner which will protect public health, safety and the environme❑ Cesspool or privy ifeet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is H annis MA 02601 May 31, 2013 required for every Y y page. Cityrrown 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 absop6tion system (SAS) and the SAS is within 100 feet of a surface water supply or tributary o a surface water supply. ❑ The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S S and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**. Method used to determine dist ce: **This system passes if the II water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates a sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, prov'ded 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 '/z 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is May Hyannis MA 02601 required for every y y 31, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable waterquality analysis. s. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"ye " or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit in 400 feet of a surface drinking water supply • ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system s located in a nitrogen sensitive area (Interim Wellhead Protection Area—I A)or a mapped Zone II of a public water supply well If you have answered"yes" any question in Section E the system is considered a significant threat, or answered "yes" in Secf n D above the large system has failed. The owner or operator of any large system considered a si ificant threat under Section E or failed under Section D shall upgrade the system in accordance ith 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 217 Scudder Ave Property Address John Czekanskii Owner Owner's Name information is Hyannis MA 02601 May 31 2013 required for every y y , page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GIRD i t5ins•3113 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every _Y y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011= 126 GPD 2012= 125 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.20 Gallons per day(gpd) Basis of design flow(seats/persons/ q.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank esent? ❑ Yes ❑ No Non-sanitary waste dischar ed to the Title 5 system? ❑ Yes ❑ No Water meter readings, i available: t5ins•3/13 Title 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y y page. Cityfrown 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: Owners records : Pumped 3 yrs ago Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance 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•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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y Y 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: Septic tank and 1S1 pit installed approx. 1980. Second pit added Dec. 1993. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4'5"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 8 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: 8.5'X 4.5'X 4.5' 1000 gallons Sludge depth: 5" t5ins•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 217 Scudder Ave Property Address John Czekanski Owner Owners Name information is Hyannis MA 02601 May 31 2013 required for every Y Y , page. Cityrown 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 31" Scum thickness 3"at inlet, 1"at outlet Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. Tank pumped and cleaned after inspection. Risers bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /E] fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scu o top of outlet tee or baffle Distance from bottom 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every y Y page. Cityrrown State Zip Code Date of Inspedion 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 ❑fi rglass ❑ 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 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every Y Y page. Cityrrown 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets w/speed levelers in place. Light solids carryover not affecting system operation. No high staining over outlet inverts. Riser brings cover(18" poly, round w/concrete square on top) within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump cha er, 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts NK- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..'° 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31, 2013 required for every Y Y page. Cityrrown 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.): Leach pit#1 6'X6'w/stone. Damp bottom at time of inspection. No standing liquid. No visible high staining over invert.#2 6'X4'w/stone. 2' liquid level at time of inspection. High water staining 1.5' below invert. No sign of past hydraulic failure. Covers within 6"of grade. 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 in w ❑ 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 ' 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is May Hyannis MA 02601 required for every y y 31, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil/ofc failure, level of ponding, condition of vegetation, etc.): I ' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is Hyannis MA 02601 May 31 2013 required for every __Y y , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 XX /z 10 �o` a sC t J t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is required for every Hyannis MA 02601 May 31, 2013 page. Cityrrown 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: >5feet 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: 1993 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: www.terraserver.com ma.water.usgs.gov You must describe how you established the high ground water elevation: Test hole in 1993 has adjusted ground water 20' below grade. Base of pit#1 13' below grade. Accessed local ground water contours and topo mapping. No high ground water in area of system. 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 ..�' 217 Scudder Ave Property Address John Czekanski Owner Owner's Name information is y 31 Hyannis MA 02601 May required for every y , 2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILL-AGE I-:iew":S ASSESSOR'S MAP & LOT 69 6 INSTALLER'S NAME & PHONE NO. &LOS c Goeu)%, g fglr6 A-? SEPTIC TANK CAPACITY 1 600 &A . LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER U tic- BUILDER OR OWNER KcLTDt,3 p'Tg0w S®«J DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; VARIANCE GRANTED: .Yes No V ., r+' . F� _, i ^ `- ' 1 � � gm ® � 1 O � � _ � 4 � � �, 1 e ` n .� I r +.