HomeMy WebLinkAbout0230 SCUDDER AVENUE - Health 230 Scudder Ave
289-068. Hyannis ,
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Commonwealth of Massachusetts
Title 5 Official'_ Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 230 Scudder Ave.
Property Address p
Stanley Nawoichik
Owner Owner's Name
Information is required for every Hyannis MA 02601 9/22/14
page. Citylrown 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 Informatioh
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford I
keyy the return Name of Inspector
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nb Company Name i. I
P.O. Box 49
Company Address '
Osterville MA 02655
Cityrrown State Zip Code
508-862-9400 S12482
Telephone Number License Number
B. Certification
I certify that I have personally it ispected 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 v luatio'n by the Local Approving Authority
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9/26/14
Inspe is Signature Date
The sy tem inspect shall submit a copy of this inspection report to the Approving Authority(Board
of H I or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a esign 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 buj::r, 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 coAcOtions of use.
t5ins•3/13 Title 5 Oflldffnspllon Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Officia[ Inspection Form
Subsurface Sewage Disposal :system Form -Not for Voluntary Assessments
230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
information is required for every Hyannis MA 02601 9/22/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Cheek A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any info mation which indicates that any of the failure criteria described
in 310 CMR 15.303 orlin.310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
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❑ 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.
' „o"Check the box for"yes", "n ,or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal aAd;over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
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Commonwealth of Mass'4chusetts
Title 5 Official,, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
information Is I
required for every Hyannis �l MA 02601 9/22/14
page. City/Town s !. State Zip Code Date of Inspection
B. Certification (cont.) i
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditional)yy Passes(cont.):
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❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with'approval of Board of Health):
❑ broken pipe(s);are replaced [IY ElN [I ND (Explain below):
❑ obstruction is eemoved ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
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❑ The system required dumping 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),9Fe'replaced ❑ Y ❑ N ❑ ND (Explain below):
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❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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C) Further Evaluation Is Required by the Board of Health:
❑ Conditions exist whicI4,require further evaluation by the Board of Health in order to determine if
the system is failing t I protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the systpm is not functioning in a manner which will protect public health,
safety and the envirdnmgnt:
❑ Cesspool or pcivy is within 50 feet of a surface water
ElCesspool or priVS is within 50 feet of a bordering vegetated wetland or a salt marsh
t51ns-3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Mas at husetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Scudder Ave.
Property Address i
Stanley Nawoichik
Owner Owner's Name
information is required For every Hyannis MA 02601 9/22/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the 6y§tem 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.
El The system has a 6eptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a 6e,ptic tank and SAS and the SAS is within 50 feet of a private water
supply well. I•
❑ The system has a septio'tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private watar supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form. !
3. Other:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or",No"to each of the following for all inspections:
Yes No '
❑ ® Backupof sewage into facility or system component due to overloaded or
clogge 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,Y2 day flow
151ns-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 17
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Commonwealth of Massachusetts
- Title 5 Offici (;-Inspection Form
Subsurface Sewage Disposal $'stem Form -Not for Voluntary Assessments
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230 Scudder Ave.
Property Address
Stanley Nawoichik n
Owner Owner's Name '
Information Is required for every Hyannis annis MA 02601 9/22114
page. Cityrrown 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 &tion 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
❑ ® tribu dry to a surface water supply.
El [E Anyofti`on 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 amrhonia 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-
10,0006pd.
❑ ® The;�ystem fails. I have determined that one or more of the above failure
cri*.6':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
nece
lIlssary to correct the failure.
E) Large Systems: To be cbrisidered 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 myst'indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area"— IWPA)or a mapped Zone II of a public water supply well
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If you have answered "yes tp any question in Section E the system is considered a significant threat,
or answered "yes" in Secti�cn D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with.310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
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Mrs•3/13 I Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth of Massachusetts
Title 5 Offici 4-inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 230 Scudder Ave.
Property Address
Stanley Nawoichik i
Owner Owner's Name
information Is required for every Hyannis ' MA 02601 9/22/14
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 °
® ❑ Pumplilb information was provided by the owner, occupant, or Board of Health
❑ ® Were'a 1y of the system components pumped out in the previous two weeks?
® ❑ Has tIle: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 al6,system components, excluding the SAS, located on site?
® ❑ Were th,3 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?
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❑ ® Was the,facility owner(and occupants if different from owner) provided with
informptjon 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:
® ❑ Existin,g 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
appro=i ation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
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Residential Flow Conditions:
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Number of bedrooms (design): 2 Number of bedrooms (actual):
2
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DESIGN flow based on 31i7 bMR 15.203(for example: 110 gpd x#of bedrooms): 220
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„ t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
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Commonwealth of Massaphusetts
Title 5 Officiai! Inspection Form
' e Subsurface Sewage Dispose !System Form - Not for Voluntary Assessments
I
'f 230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
information is i
required for every Hyannis MA 02601 9/22/14
page. Cityrrown State Zip Code Date of Inspection
D. System Informatio'
Description: h-
Number of current residentsi, 2
Does residence have a ga'bage grinder? El Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No
information in this report.)j,
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
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Water meter readings, if available(last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
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Last date of occupancy: currently
_ Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank'present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
o Subsurface Sewage Disposal tystem Form - Not for Voluntary Assessments
t •
230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
information is required for every Hyannis MA 02601 9/22/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
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General Information
Pumping Records:
Source of information: _pumped in 2013- per owner
Was system pumped as part of the inspection? ❑ Yes ® No
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If yes, volume pumped:
gallons
How was quantity pumped d6termined?
Reason for pumping:
Type of System:
® Septic tank,"distribution box, soil absorption system
❑ Single cesspool
❑ Overflow Cesspool
❑ Privy
❑ Shared systl� (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):
I51ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Officials, Inspection Form
Subsurface Sewage Disposal Pystem Form-Not for Voluntary Assessments
II
230 Scudder Ave.
Property Address it
Stanley Nawoichik
Owner Owner's Name
Information Is ti
required for every Hyannis MA 02601 9/22/14
page. Citylrown ( I State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all corn,pogents, date installed (if known)and source of information:
installed on 6/23/1997 -pei,;as-.built
Were sewage odors detec�ed when arriving at the site? ❑ Yes ® No
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Building Sewer(locate on site plan):
Depth below grade: III 1
t feet
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Material of construction:
❑ cast iron ® 40 P�VC ❑other(explain):
Distance from private watar supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
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Septic Tank(locate on site plan):
Depth below grade: P 12"
feet
Material of construction: 6
® concrete ❑,metal ❑fiberglass ❑ polyethylene ❑ other(explain)
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If tank is metal, list age: I
� years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
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Dimensions:
1500 gal.
Sludge depth: 2
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t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
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Commonwealth of Massachusetts
Title 5 Official' Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
Information is required for every Hyannis MA 02601 9/22/14
page. City/Town State Zip Code Date of Inspection
D. System Informatinh (cont.)
Septic Tank(cont.)
Distance from top of sludgy to bottom of outlet tee or baffle 33
Scum thickness 2
Distance from top of scum,to,top of outlet tee or baffle
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Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees were present. There were no sign of leakage.
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Grease Trap (locate on site plan):
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Depth below grade:
• feet
Material of construction:
❑ concrete ❑ mptl'l : ❑ fiberglass ❑ polyethylene ❑ other(explain):
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Dimensions:
Scum thickness
Distance from top of scum"totdp of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
151ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Mas4achusetts
Title 5 Officials. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
230 Scudder Ave.
Property Address '
Stanley Nawoichik
Owner Owner's Name
information Is
required for every Hyannis a MA 02601 9/22/14
page. CitylTown j State Zip Code Date of Inspection
D. System Informati 'Iq, (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.):
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Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ mpt' I , ❑fiberglass ❑ polyethylene ❑ other(explain):
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N/a ,
Dimensions: l
Capacity:
gallons
Design Flow: l gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alar)'n and float switches, etc.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•3/13 Title 5 Oflldel Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
f Commonwealth of Massachusetts
-_-- r Title 5 Officipl Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owners Name
Information is required for every y
r Hyannis MA 02601 9/22/14
requir
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if prese;nt.,must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box was normal.
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Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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" 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):
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If SAS not located, explainwhy:
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t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 12 o117
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owners Name
Information is
required for every Hyannis MA 02601 9/22/14
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 - infiltratorswith 4'stone
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fie4ds 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.):
There was no sign of failure from chambers.
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Cesspools (cesspool must be'pumped as part of inspection) (locate on site plan):
Number and configuration
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Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
4
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
I51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
h
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Scudder Ave. "
Property Address
Stanley Nawoichik
Owner Owners Name
information is
required for every Hyannis MA 02601 9/22/14
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.):
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Privy(locate on site plan):
Materials of construction: i
Dimensions
Depth of solids ,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
t5ins-3113 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
230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owners Name
Information Is
required for every Hyannis MA 02601 9/22/14
page. Cityrrown II 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
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tSlns•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
r 230 Scudder Ave.
Property Address
Stanley Nawoichik
Owner Owner's Name
Information is required for every Hyannis MA 02601 9/22/14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
l 15, +/_
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;l(abutting property/observation hole within 150 feet of SAS)
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® Checked with local Board of Health - explain:
Topo and water.contours map
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❑ Checked with'local excavators, installers - (attach documentation)
❑ Accessed USES database-explain:
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You must describe how yC+u;established the high ground water elevation:
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see above
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
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. Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
230 Scudder Ave. '
Property Address
Stanley Nawoichik
Owner Owners Name
Information is
required for every Hyannis MA 02601 9/22/14
page. CitylTown 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— Estirhated depth to high groundwater
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® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
T OF BARNSTABLE
LOCATION C � SEWAGE #
C
VILLAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. !:)Ca -.-Sty,�
SEPTIC TANK CAPACITY AbU CK — C?6>C
LEACHING FACILITY: (type) _(size) S
dr-NO.OF BEDROQM G�
BUILDER OR OWNER f[c,�._t
PERMITDATE:-Q jr kill COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility it/ 2a' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) k01- c Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of 1 aching facility) Feet
Furnished by
6
Gc,rc,l
A+oH b
-cam O Cox 33
Q. 9 0
4 A-6 p 3CO
_ D
No. � ..-- � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for Mizpaal Opotem Conotruction permit
Application for a Permit to Construct( )'Repair(✓ )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ;Owner's Name,Address and Tel.No.
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1/ c.K..
Assessor's Map/Parcel W1111S a3V V d r A,/4—A,/4— t S
Installer's Name,Address,and Tel.No. S_ yS/r-b Designer's Name,Address and Tel.No.
aC�( otc�-,k (Q H t^Z J Mk as 6 01
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank j.::QO . Type of S.A.S.
Description of Soil
9,Z0kt cJ_ C c s F l cW Z x Gam,L &^t c
Nature of Repairs or Alterations(Answer when applicable) ,�
Date last inspected:
Agreement:
The undersigned agrees to ensurelthe construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the F
aukemmrntal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thisLBCd Health. C
Signed 19 Date f 1
Application Approved by Date
Application Disapproved for a following reasons
61 A I
Permit No. Date Issued
I
TQ4VN�OF BARNSTABLE
LOCATION y<JCJ'Q�
,. r SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT22
INSTALLER'S NAME&PHONE NO. 72,�-� y y
SEP`ITC TANK CAPACITY U
. LEACHING FACILITY: (type) (size) &�Gf .
NO..OF BEDROOMS �� ��(� v^`O--
BUII::DER OR OWNER cC�:
PERMrr.DATE:--G u k1l COMPLIANCE DATE: lS 7
Separaon Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility —A & Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 2W feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of! aching facility) Feet
Furnished by
LJ
8 D zo a
_.,.
310
No. i x�E- Fee
THE COMMONWEALTH OF MASSA HUSETTS _ Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNS ABLE, MASSACHUSETTS
Zipplicatton for Mtopp$al *proem Conf&uctton Permit
Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
a 30 ��/�)
Assessor's Map/Parcel YNA/ !s a l o _S-_V d ck e- Af{— H t S
Installer's Name,Address,and Tel.No. > )S_ S'b C�Cj Designer's Name,Address and Tel.No.
0?6,01
Type of Building:
Dwelling No.of Bedrooms a_- Lot Size sq. ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I��U . Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)�tp��c:�- C(SSR001 (nl //TVO &C L A�4
+
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 tal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi B and�ealth.
Signed A o Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
------------ --------------- ----------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( )Repaired ( Upgraded( )
Abandoned( )by Lc -P 'Mow G CC%/\_< < /_
at C-D 3c) S hC. S h constructed in accordance
with the provisions of Title 5 and the for Disposal System Cons ction Permit No. dated
Installer Scc� c-\ FC-c-^ 4_ Designer
The issuance of this permit shall not belconstrued a -a guarantee that the system will function as designed.
Date l., 1 !71 �'� —Inspector —�
No. I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mioogal OpMe Conotruction Permit
Permission is hereby ranted to Construct( )Repair( )U grade( )Abandon( )
System located at 30 Sc j� 6 eu Aki-C- -�y�,,,,�,�s
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/he duty to
comply with Title 5 and the following local provisions or special conditions.
O a
Provided:Co do m b ompleted within three years of the date of thi
Date: Approved by
i
NOTICE: This Form is to be used for the Repair of Faired
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, �CdS hereby certify that the application for disposal works
construction permit signed by me dated ('„ f&�� 7 , concerning the
property located at 5 C sLr A meets all of the
i'
following criteria:
There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
L. There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER'
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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