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HomeMy WebLinkAbout0277 SCUDDER AVENUE - Health �277 Scudder Ave , Hyannis I No.�_) i� 1 Fee -7 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye ftplitation for VspoSAY *pstrm Construction permit Application for a Permit to Construct( ) Repair(grade(^ ) Abandon( ) ❑Complete System [l Individual Components Location-Address or Lot No. 00 Owner's�Iare,Addresg,and Tel.No. /Z- + �Z���jCeta�i 3 f�� (/C.l�ra�c/ ` Assessoeg---Map/Parcel Ins er Name,Address,and Tel.No. Off` ��'�? Designer's Name,Address,and Tel.No. vb ✓�(�et�f/if �'fma�' �o eO J'Cvf<G S�m'[xr= 3,S-O o•' �� tom. .-..Jv 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. Signe I Date ? Application Approved by Date - Application Disapproved by Date for the following reasons Permit No. �'© �� ' 1 Date Issued r._r..%;...3�•'*ti:�.-''i.-�. •....,,—«i^:R -:•r`n'Q�--^'„s:,r.yi,-�ltr..+'?-,�}, _,,..—,-.•*r,,r ,,•'ra"�.ti^.' .,�:.— , f'r`^ r-`.�,r.�;�_ •��,��� r�r M1� ;,, ,;N � ,".FT.ti No. u Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(-)'Upgrade( ) Abandon.( ) [:]Complete System ❑Individual Components Location Address or Lot No. ?J;�r d;Py O 0 3 Owner's arrlp Addres ,and Tel.No. Assessor's Map/Parcel �.�,�;�,� 2PT' S Cvo�✓y �, //" �y„��i Installer's Name,Address,and Tel.No. ��' 77 �d'�t_ Designer's Name,Address,and Tel.No. �b� ✓'�CFa-fig/ �''.�,�rm l"cd� .�'•�'"t:"/iG S+aGe�;, Type of Building: t Dwelling No.of Bedrooms 3 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. � -Descriptiokn 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. 4 Signed\ "�-= Date Application Approved by \� v '" Date 7 1 1 Application Disapproved by Date for the following reasons Permit No. Date Issued `� ' � �i r THE COMMONWEALTH OF MASSACHUSETTS Z '- BARNSTABLE,MASSACHUSETTS Certifirate of Compfiance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ol ) Upgraded( ) Abandoned( )by -r.�.��•* !v t�af�c► /%c� ,s-'sr '�ii^ ._ �-�ci� � has been constructed in accordance with the provisions -o-f Title 5 and the for Disposal System Construction Permit No.-r l&-1)ltdated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will flu c tttt on as desig�need. Date -7 /q Ins ector� ---------- NO. Q» .� Fee 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(Z�) Upgrade( ) Abandon( ) System located at ,413�Pir�� 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 -7 . Date - t Approved by \ t Town of Barnstable BAMSTABM Regulatory Services Department Ar fp�,t a Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool p,Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER 7 U- Qgy Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1`� F; 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name / MA 02601 7 sF Information is `/ r� required for every Hyannis -5-18 t page City/Town State Zip Code Date of Inspections Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information rms onng out the computer, \```�.� 4�N OFr. use only the tab ��� • ' 9C, key to move your 1 Inspector: �oz: cursor-do not James D.Sears :�; JAMES m= use the return Name of Inspector RS y key. Capewide Enterprises �� Company Name i,��' .,R . rd . .... � 153 Commercial Street ''oF,yt I ? � Company Address Mashpee MA 02649 City/Town State Zip Code 5087477-8877 S1623 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 7-9-18 spectoes 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 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. t5ina.doc•rev.6l16 Title 5 Official Inspection Form:Subsutface Sewage Disposal System-Page 1 of 17 li b a5ed xe:1 dH 6£:£Z 860Z 06 lnr Commonwealth of Massachusetts Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 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: Conn Pass. The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. `A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Mns-doc•rev.6116 Tple 5 Ofticlel ftpectton Form:Subsurface Sewage Disposal System-Page 2 or 17 g a5ed x2J dH l.&£Z 860Z 06 lnf Commonwealth of Massachusetts fi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name information�s Hyannis MA 02601 7-5-18 required for every page. Cityrrown State Zip Code Date of Inspedion Be Certification (coot.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont,): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Need to replace D Box. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh I t5lna.doc•rev.6116 Title S official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 9 a5ed xe:1 dH 6£:£Z 860Z 06 lnr f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 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 the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet ir.vert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than Yz day flow Pd T t5ins.doc•rev.6116 This 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L abed xeJ dH I,&EZ i360Z 06 lnr r Commonwealth of Massachusetts Title 5 Official Inspection Form Ir Subsurface Sewage Disposal System Form Not for Voluntary Assessments .V- 0 277 Scudder Ave Property Address Carla Aiello&Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 col iform 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- 10,0009pd. ❑ ® 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)I Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no".to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins.doc•rev.6,116 Title 5 Official Inspeolion Form:Subsurface Sewage Disposal System-Page 5 of 17 9 abed xed dH ZEU 860Z Ol. tnr Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v r 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name Information is required for every Hyannis MA 02601 7-5-18 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? ❑i ® 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 NIA) ® ❑ 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 Conditlons; 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 tans.doe-rev.6m Title 5 Official Inspector.Form:StbsuAace Sewage Disposal System-Pape 6 of 11 6 abed xeJ dH Z£:£Z 860E 06 tnr P Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 per. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 4 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 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: 1&na.doc rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 06 a5ed xeJ dH ££:£Z 8l•0Z 06 lnr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 Paw, City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.dcc-rev.W6 Title 5 Official hspeation Form'Subsurface Sewage Disposal System-Page 6 of 17 66 a6ed xeJ dH ££U 860Z Ol, lnr f y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is Hyannis MA 02601 7-5-1 S required for every - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1993 - Permit #93-633. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeina is 4" PVC - SCH -40 Septic Tank(locate on site plan): 1011 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 3" Sludge depth: + t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Z6 a5ed xed dH ££U 960Z Ol. tnr f Commonwealth of Massachusetts lo Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form •Not for Voluntary Assessments S 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is H annis MA 02601 7-5-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 1 Distance from top of scum to top or outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Abuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level. Tank and cover's at 10". In Tee,out baffle. No sign of leakage or overloading. Grease Trap (locate on site plan): Depth below grade:. feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions' Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum.to bottom of outlet tee or baffle Date of last pumping: Date t5in3.00c•rev.8116 Title 5 Ofriolel hspeotio-i Forth:Subsurface Sewage Disposal System•Page 10 of 17 £t a6ed xed dH ££:£Z 8l,0Z 0l, lnr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner owner's Narne information is required for every Hyannis MA 02601 7-5-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan). Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins:doc rev.6116 Title 5 official Inspection Form'Subsurface Sewage Disposal System-Page 11 of 17 t,6 96ed xe:1 dH 'V£U 860Z 06 lnr c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name information is Hyannis MA 02601 7-5-18 required for every H Y , page. Cityfrown 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.): D Box is 16"x21"-2' below grade wlone line out wall's are done on Box. Need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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.doc ray.W6 Tito 5 Otficial Inspection Form:Subsurface Sewage Oisposal System-Page 12 of 17 gt a5ed xeJ dH b£U 860Z 06 lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l' 277 Scudder Ave Property Address Carla Aiello & Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-16 per. cilylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ inn ovativeJaltemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit w/2' stone. Pit at 57"below wlcover at 31". Level in pit at 20" below top of pit Note: Pit is piped into riser. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins.doc•rev.3/16 Title 5 Official Inspection Form.Subsurface Sewm®e Olsposal System-Pam 13 of 17 gt a6ed xed dH bE£Z 860Z 06 lnf Commonwealth of Massachusetts Title 5 Official Inspection Form iiy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello& Eric Hiliebrant Owner Owner's Name information is Hyannis MA 02601 7-`5 18 required for every _y Page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- t5ins.cloc-rev.6115 Tillo 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L6 abed xed dH S£U 860Z 06 lnr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 277 Scudder Ave Property Address Carla Aiello& Eric Hillebrant Owner Owner's Name information is required for every Hyannis MA 02601 7-5-18 page. City/Town 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 _yea NT A r o l0 2 0 QQ J era=�E-7 t5ins.doc rev.6H6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 g t abed Xed dH S£U 8l•OZ o l• lnr Commonwealth of Massachusetts Title 5 Official Inspection Form is U Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ep 277 Scudder Ave Property Address Carla Aiello&Eric Hillebrant Owner Owner's Name information is Hyannis MA 02601 7-5-18 required for every State Zip Code Date of Inspection page. Cityfrovm D. System Information (cons) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N-a 15'+ Estimated depth t 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 propertyfobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Lot High from street and abutting property. Bottom of pit at 107' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev.6116 Title 5 Official impeclicn Form:Subsurface Sewage Disposal System-Page 16 of 17 61, a6ed xeJ dH SUZ 81.0Z 06 lrr Commonwealth of Massachu setts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 Scudder Ave Property Address Carla Aiello&Enc Hillebrant Owner Owner's Name information is Hyannis MA 02601 7-5-18 required for every State Zip Code Date of Inspection page. City/Town 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 15ins doc-rev 6r16 Title s official Inspect on Form.Subsurtece Sewage Disposal System•Page 17 of 17 OZ a6ed xed dH S£U S60Z Ol• lnr r-1 . �p oZ 11-5 o� mmonweaiin or massacnusetrs Title 5 Official Inspection Form a s- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is required for HYANNIS MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use Inspector: only the tab key 1 Insp to move your DOUGLAS A BROWN t "'111111 lJC ���YYY cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name tad P.O. BOX 145 �. Company Address CENTERVILLE MA 02632 City/Town State Zip Code 506-420-4534 S 142g7 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 1 oll' a 4� 5/5/11 InspectoKleSignature 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 t 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. W I t5ina•0908 l I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonweaitn or iviassacnuseiis uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name , information is HYANNIS re uired for MA 02601 5/5/11 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: �I 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 8) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be. replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic,tanik will pass inspection if it is structurally sound, not leaking anu if as ve,tificote Of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 T .._ Commonweait._n or massacnuseits Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND Explain halo ,1: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Imo____________ �_.ah L �� .___�_aa� �ommonweaitn or massacnusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. Cityrrown State Zip Code Date of Inspections 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: 4 ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The SA system has a septic tank and Y p S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) 14yst6 mr Failure Crii`aeiia Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No r-t ra Backup of sewage into facility or system component due to overloaded or u VS1 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 r-f ,pl Liquid depth in cesspool is less than 6" below invert or available volume is less L' than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 �� kommonweaitn or massacnuseirs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS cesspool or privy is below high ground water elevation. 72 ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a public well. I ❑ 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 qualit anal sis.Y Y [This i system passes f 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 anal ysis 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. rj The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the.Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 f et f a surface drinking!,� ,s._m " e_,o. _ _ kin'water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If�� iw have answered"yes" ^Mn�i rn 1e3tI^ n e�4I n he �u to c considered a cin lfl^,$nt threat, ,o ,e "t , ,,., n i -Section E t ,s m i consi sign or answered"yes' in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 \ Corr-nr-ir onweaith Of Massachuscatts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS re uired for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ N Pympino information was orovided 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 Y p two week period? ❑ L7 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? ICI IJ-I Was the site inspected for signs of break gut? ❑ ❑ 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: IRI 1=l 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): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310(�__ _ 15,20 (f r e_ample, 110 a d 490 GPD AMR 3 9. x_m� _ _ Jp-x#gf bedrggmg); OFF PLAN t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Bill achusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PLAN SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 6 FT DIAMETER PIT WITH 3 FT OF STONE Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No i Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings; if available (last 2 years usage(gpd)): Detail• 2009=131 2010=119 Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT 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: t5ms-09l08 Title 5 Official Inspection Form:Subsurfac e ce Sewage Disposal System 9 Posa ys Page 7 of 17 Commonweaitn of massacnusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 SCUDDER AVE Properly Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. Cftyrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I t5ins•0910 Tide 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 8 of 17 Commonweaitn of Massacnusetm Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection D. Svstem Information (cont.) Approximate age of all components, date installed (if known) and source of information: SYSTEM INSTALLED 3/22/85 Were sewage odors detected when arriving at the site? Ell Yes La No Building Sewer(locate on site plan): Depth below grade: feet Material of constriction. ❑cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage etc.).- Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑metal ❑fiberglasspolyethylene 9 ❑ ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: t5ins•09ro8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth Of IvlaSSacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunt ary Assessments M 277 SCUDDER AVE F roperty Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 every page. Cdy/Town State Zip Code Date Date of of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK COULD USE PUMPING AT THIS TIME Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y • ❑ other(explain Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 commonwealth of IviMassachusetts uTitle 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. Cftyfrown 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.): TANK STRUCTURALLY SOUND AT THIS TIME NO SIGNS OF LEAKAGE Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ms-09= Title 5 Official Inspection Form:subsurface Sewage Disposal System•page 11 of 17 f �____________ __.t._ f ._____aa_ �ommonweaitn or nflassacnusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 SCUDDER AVE Sv r Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) locate on site plan): P ) ( P ) Depth of liquid level above outlet invert On Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box etc.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ® Yes ® No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: z t5ins•09/08 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I,� f Commonweaim of massaunusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) i Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches . number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIPE COMES INTO PIT THROUGH CONCRETE RISER, SOME ROOT INFILTRATION INTO PIT, ALSO A SOIL LIKE SUBSTANCE IS HANGING DOWN FROM INLET PIPE INTO PIT BUT THERE ARE NO SIGNS OF FAILURE AT THIS TIME PIT HAS ABOUT 2 FT OF USABLE SPACE Cesspools(cesspool must be pumped as part of inspection) (locate on site plan);- Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•OgroB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Coifimoi�weaitn of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. City/Town State Zip Code Date of Inspection D. Svstem Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ine-oatos Title 5 Official inspection Form; Savage 91speE2i system.page 14 of 17 r Commonweaitn of IV�aSSaC�illSett$ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately t5ins•09108 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 M '( 277 SCUDDER AVE Property Address PATRICIA BLOOM Owner Owner's Name information is HYANNIS required for MA 02601 5/5/11 every 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: AT LEAST 4 FT feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: ATTACHED Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ms•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonweaitn of iviassacnuset Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 277 SCUDDER AVE F'roperty Address PATRICIA BLOOM Owner Owner's Name information is Owner's required for MA 02601 every page. City/Town . Date of 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 (Sine.SAN)& IbT'a 5 . __O[Reial inegeeNon Few Sygcurfage Sewage Dispose!System.•Page 17 of 17 d--V LOCATION �y S' EWAGE �yPERM/IT No. VILLAGE I N S T A LLER'S NAME i ADDRESS ® U I L D E R 0R OWNER DATE PERMIT ISSUED I DATE COMPLIANCE ISSUED r z y L.. 1 o � i i , /YO7"E /F.FITNER TtIE.SEPT/C TANk OR `� 20 FT. M/N• L—=,4GHI,lG P/T ARe JIOA'& TNAN /2` JZLO-k / * GRA Off, /a MAN SNAPLL �i� ®JP006 4lT Ta 6Jys40E.�AN EX'rR� 40PVC O/P/Z /,r=,4vY CAST IRON CO{/.--h' .SfJAL-I— DE USED ` CONC.4'�T� MIN. P/TC 4..� CO1�1�J�S I F//V OR/VE1�VA Y / ArR — 2 MIa. C'DNCR.�TE A :;a ty Ao& CO YEOa' GLEAN .SAND i . _ *LAYER IRON:P/Pf 0 0 • r • • a o rJ . . • a e 1e _AL.. a G Jt� E a WA S N •�:b' M/N.o>Tt/0 Cry-}' /. �/ D1ST. � • . • • • a / e . W Sbr/Ii. TAN!'l. goX O 1 4 ; ' ® • i�_. • • • 1 dip • Et_T" D • • : ° e ► • o DEPTtt ° °.` ' v o Iy,43XE0 57D/YE s 0 a a j•`a.. O •113 REIAiST SE,F.�'l4Gg' •: P J a PIT DR gQU/s o 0 J °a�-O lNYERT AT &/1/4®/NG l FT. 3 G D/AM. JMLET �s��T/C' TANK 39� FT, /z F7; O/Alm: rf1BULA7'lOso/� Dtl?L.=T SEP7'/C 7ANit Pl57R1.8 IY/®N BOX 59,9 4 C7 . SECT�O J 0.= GROu/e/a e�'�I� �� E 1AlL=r 00 LZ7D/57'R L4tY/ON X 99. z rT. S� ✓�Gi� �I.S®> s��. S�•ST'��`7 /INLJ�F'L.F.RC/>'/R/Cr F-l-r 9 9• FT. 'TAjVL.AT1401V LC�6//!/G s/?' �3/m ENV/ov A XT D/NfNSt®N — —FT. D/I�2JdS/Ohl C 4 FT; /tl,.✓; mesa aG�o/S�o s,�� t/N/r Nn.✓E .. SOIL_ L.O& TOTAL �.v'T/I lA71-Z D j0=40 / 3 3.c f G. 41L 140AV DSO/L TEST 0/ SOIL T.�STOR �®��. �'a��T A/UmaEh''G.,� AtCMIMCe PITS ! F"LEE/. /©3, {� EL Y AOA7'E O/:' $®/L. TEST, S/OE 4.eACl-!//!(Cv P—=1R R ! s/ SSY; dw v- (� " RESULTS Y 4(9077r0Al LZ4CHIN&POR Plr II 3 � Ry . cozA 'oN l A-r.V A&/ Liss ,,,y/Ag/lNCpd TQTAL L€ACH//VG AREA 2-(o 4.So. FT. a SRO®1A'T/BN/F'F'.�7"� � T 7'`�>`�l`'9t11d.�JIVC�f .4E.SERd--,c'LEAC*N1,l/Cr AREA ' SQ.. F7' , f�c �LTE c4, P�(t1OFM41,s�s a'i1 F3RUCE A. ,. t p., L�Oru i ELD�E w o MORSE us s'ot ill .Y ,o lic�109'51�o o� cis �``,�, L 9 t'• D . -J 7/2 Mps4 IN,.3t:� ,• NYANNl3,MASS y'•+ev awe FS sioN�t a. : 3 Cc%�M7' e sU rj"UV>, W,4T , ll - R10 T Y J 3 o uwo s� LOCATION HaU�� SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME A ADDRESS s B U I L D E R OR OWNER DATE PERMIT ISSUED LZ s DAT E COMPLIANCE ISSUED 3 . �� �- i a �. �� ^,. y '7 \� v �� �� � ?t N Z � �� -� ��. ti 1 No........... .......�0 Fizz.... ............... - q>���yp THE COMMONWEALTH OF MASSACHUSETTS �SBQAR® ®�' I-iEALTI-� / Q' � ! . OF..............tz�_v_ 1.. .v....�....... a17 Applir�a#ion for Uhip salnirurtion Prrafit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. r1 —5 ..c�. ' ', -------------- �r.�/._- ........... �C;W Address Y... - ... ..- r /./.U!.fl.... Address........................ Installer � _ Sq. feet Type of Building _ Size Lot....................._..... Dwelling—No. of Bedrooms.... ................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers' ( ) — Cafeteria ( ) a' Other fixtures ...........-•-----------•-•-•----•-•-------------- • . W Design Flow............................................gallons per person per day. Total daily flow........... �..............gallons. WSeptic Tank—Liquid capacity/ gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank, ) Percolation Test Results Performed by..........J99L60 ....................................... Date......... Test Pit No. 1. minutes per inch Depth of Test Pit.................... Depth to ground wat r_.__ / 1VI Test Pit No. 2_ �l!OAiinutes per inch Depth of Test Pit.................... Depth to ground water................... ----- O Description of Soil.......................................................... ....... ....... CL...---------------------...........---•----- W ••-•-•-••-•------------•••-----..__...••----•-••--..._..---•------------••••........-•----•--•---••------••-•-•-----••-----------••••--••••••--•••-•------•-•---•-•-•-•---•••-•-•--•-----------•-•...... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..------•-------------------•---.....--------------•--------------...---•---------------•----•----------.......---------------•-------------_--------•------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operatiQn juntilal.Cert' to o Compliance has been issued by the board of health. Signed............................... .� ... �Dat Applicaatt!i�olnn Approved B ------ ----------• -••--_-- ------. � 5-------- Date Application Disapproved for a following reasons: ----------•----------------------------------•---------------------------------•-•---•------•- -•-------------•-----•---•--------------------•-----•-•--•------------•--•-•---•-----------------------------------•---------.....---•••------------•--•------•--- .................................... Date Permit No. .e?5 S> ..... Issued.............. -r ................ Date 06 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -- -------C7- _.:. ......OF................. .................. ---............. #ila� flan` �i��rr�tt1 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: v ....... ��................�.5..' v.�' F1z. vG �f'r , lr!/5. f-1.7..................----------.........--- Location-Address or Lot No. Owner ` _ Address w f. Ald �',/1. - .... /�l/ U._4' 'l ?�..----..•---------------------------------------------------- Installer Address Type of Building Size Lot............................Sq. feet Other—Type . Bedrooms ................. - ------------•Expansion Attic ( ) Garbage Grinder ( ) a Dwelling o. of Bedingms__:.._._ No. of persons............................ Showers ( ) — Cafeteria ( ) QIOther fixtures -------------------------------------------------- - W Design Flow...........................................gallons per person per day. Total daily flow...........&.,2 2.............._gallons. WSeptic Tank—Liquid capacity/.gallons Length................ Width................ Diameter_............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `�' Percolation Test Results Performed by..........J-Z are ._! ............................•......... Date.........10 ..__Y415 a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground wat r---- . fT4 Test Pit No. 2,O9-O llinutes per inch Depth of Test Pit.................... Depth to ground water... a ............................................................. .............................................. 0 Description of Soil........................................................ f--... ----.-`. / GC------------------------------------------•---- x c, ---------------------------- W -•-----------•------------------•--------------------•----•-----•--••---•---•---•---••••--•---•-••---•---•---••-------•-•-•-----•••-•-••------------------•--•-••--••----------••-•-•......-••-----•---- VNature of Repairs or Alterations—Answer when applicable..............................:........................................__..._.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operati- until ,a Cert sate Compliance has been issued by the board of health. • f' Signed..............................L--------••-----------••---- - ------------- - --tip---!-�� Da Applilcation Appro/ved $3' _&. $----------------- r = �► Uate Application Disapproved for a following reasons-------------------------------------•-------------------------•----------------•-------------••••-------......- -----------------------------------•------------------------------------------------.....-•----......-----••-•----•.....---•----••-------••------•-------••-•-•••-•••••--•••••......-•-•••......-•-•--. Date Permit No--------��-+.'.�`_ (14 : Issued--•--------•-L---Z-- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OFfie .......:...:...................................................................... Trr#ifirtt#r-oaf Tamphaurr THIS IS TO CERTIFY That the Individual Sewage Disposal System. constructed or Repaired ( ) by----------------------_-- / ... ' / �1 T ---...---.................--------------....-------------------- Installer has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code s descjibed in the application for Disposal Works Construction Permit No....... .......... dated--------- ---T......_..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUA' NTE THAT THE SYSTEM WILL FUN TION ATIrrSFACTORY. DATE.............. ...... .... ..&5........................... Inspector---.---� ...... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................:........O F..........................................._.._................................._.... No......................... FEE........................ Permission is hereby granted 7 '.ffl �� �UCH .//(� ....... to Construct ) or Repair ( ) an Individual Sewage Disposal System atNo............ .............................................................................••.---------------------•---------------••----•••-•-•-•----•-••-•••--•---------••---......._...... Street as shown on the application for Disposal Works Construction Permit No ---•--------•-•-- Dated.......................................... -_.....- -------------------.............. • Board of Health DATE ---=�. . . ......•------------------------------------- FORM 1255 A. M. SULKIN, INC.. BOSTON ` L_p a471 TL co fy �. U ` I- Ol •I � ter' , 1 o '- 22,. \ -� 3 N �Jt7t) QSJ"• �vo 'woai�r S�7F3sFGtS r F M�ss� `per 02 ' AL Gu, Z— 07 2 3 0 1lORSE co ST No 10951 CENO _ CERTIFIED PLOT PLAN 4 xEXISTlN(3 SPOT ELEVATION OxO r �. _ n.f.Pg�cs�� xEXIS:TIId® CONTOUR ___. ® __ 4, -.` ,�•, �.or z4 x. j F1I*I13HED SPOT ELEVATION ,,� r, - ` !/� `, `�� ,f , ROBERT n a , FIP4I SHED CON,T0 R O f aRuCE S N u .ELUREUt3F "PROVE;D BOARD. OF HEALTH ` �� .XJ���. �.�, ��' + - - �` ti .p�'TE A4ENT SCALES / = 30 DATE� `I 7 /25 h, L: l4DGE ENGINEERING-Co- IN �, • _, - CLIENT. I CERTIFY THAT THE PROPOSED or &q4 U Z3 BUILDING SHOWN ON THIS PLAN EG19TE.RIE REt�ISTLREO ' JO® N0. rk ; LAND'" CIV:IL`- A .A /''/ CONFORMS TO THE ZONING LAWS E 0 EER URY Y R DR.BY' --- OF BARNSTADLE., MASS , r'c ✓f 712 M'A I.N' STREET CH. 8Y t 1Z• t3. f4AP YANN IS, MASS:; Z .SHEET..,...'OF RE6. LAND . SURVEYOR ap FT. M/N. /VOTE /F FiTNFR 7sre SEPTIC T�►NK OR LEAGNIwG P/T .4RE MORE TI+IA/V /a`1 SAL 0PV Z4 w P1AMET.ER CO/yC^FTAW. COvtR,r SIJALL 8E ®EOtJt�NT TO G/�AOE.�AN EX? /7F,6AVY CAA • GONGRCTE ¢'PVC O/PE SrST /R O/V CO SAIA j/�R I L SE USED ' 4:.� C'OilERs MIN. P/TCHV.-WA _ 2% MIN. C"ONCR�T.E i s I c� AOE Co KEft CLEAN .SANG I ti z LAYER OF D t000 • - i M/N.o/TCI+r G/IL. D/ST. 1.• • ., • • • • > ,� WASHED 57DIVE %4 PER. w $APT�/C TANfC • e • • • • • • • • e • e a • / • re ♦ DEPTH • ♦ e • 1 r dp WASNEO 570 i y _ 113 x / p — 113 . • . • ♦ ® • e • • • • o • s PRECAST SEE'A)IGE • a1.. o • Y Jr CA v c.r T y 4 q o .ca,9 c/�^/ r o P 7 DR u� . r INV E T 6•� D/AM. 3 'INLET APT/C` Ti4/V/r 99 S FT, /i4l�J. C(see TA®uL.�rJoev� dvTL'ET S&PTJC L TANK g9,6 ITT. lwtFr P,smi4avrlom sox 9 94 F7 - SEC770/v o� GRou/vo . A�E/� TA�c.E O�ETD/S77t/®t1T/OJtiF�X 9 g ? rT . . _ - . I/VLT cFAct/iaG PIT g 9•o FT SE'�V�BG� O/.�io �L S9�.STWM Ti4X11s071401 / P0T oJME/vrsJ®Jv A �T.. DES%GN CRIT� /�4 scAL.E 4 All Al., N!lMQER. OF�SE�RO�,S � 3 � - DJMSNSO®N G T. G•ReAGEbzSPosAj_ //o,�E SOIL LOG TOTAL Al3T /►'l47Z=D, FLO/R/ 3., 0-4l DAY SO TE$,T A/ SO/4 71CS7-**2 S0111 T�` 7'. ' Xu/�9�ER' t,E�CNIwD, P/73 f Fce�a! �o rEt�a� O.�TE OF' S®JL' TES7 d 3 3. y / z A ACAilM PER P/T l / ,5 .�7:, C�= (� �' RESULTS dt/JT/VES�E® 8Y �I •g'cam•�f c ®OTipi/y AA4c YIA a PL=1�P/T /!3• so RT l f vrYt u S A,—JV COLA-r10W AA7-JF Aft L SD W!/1ll'I NCH TOTs41 LEACH'//YCr .AReA: S� FT. NCOL /V AT/® RAr MJN�ll1/Cll' �' S sarL PE NCO 3 z v {RESERYELEACHlN6 i4REA �4 SQ. FT. � , � l/ � _ •gym : ,�,, S6iiY�' v`'OILTEST OF Mosst/EC_ yDI�;e-p— ,A VC mow. •"\ -n� �Q. fro ._ �;.. .- „ :. OBERT BRUME A ` jai L=%mil a ELuRE MOREE - No lo951 E1OR�'I3 � IIVJ�/J CQlN - , /L.,/►9s4lNg7:'j+ Ny N/5,M:4SS r sro � p .. �, tic. ,:;, r .,.:`. ..., FFS NA .F�, -r.x SU r ( Nd Psl�OlJIVD"YY47C•I AIVCOEJIYTJ�4O CA 6 "4 '... ... .._s y. -,:ti r.`* u,-. :�t.��:r(,. .c,i.r, •.,. . t ,« :�. {/+yam t.. ) ,,... .... r- ._.�"` ,' `. ,. -..- .,y;•t.. { .:�._. � ya.-� i_,y`,,.:'.lV a ...... .. .. .. ...� ,A........_ ..,, :.._. 'k � :,, ,.. r ,,-pt"6 �._.T[. fit'. sr.,.-� t .r i I w�"•� � i:: .# -.v'p:�' .`r'-w a? -'J:f.` ;, Y.,. _-.:.k.. ,...u..e :.., . 's. .-,: , :9?t.G:..,_ •a '�. io ,.E ,: _i...¢,,.. ,.,: ✓ ,..,.. ,. L; a „ x,.r,'� .v- _:- 4- ,:��.. 3.�" :cw t '�" ... : ...... ,..�.. >: ,...K..w.-.Y -.,..n:...; _..�.,. ,r ..� .. .:�a,'�' ><•rt ... .1, 4' .�. ,4�. -«�. r x .,.-,-.. #,y n,�-�' r•,e t.✓... M k a•4 ,'A�.kr a Y.:.. •'.M_ 7� `:C�� �y �.. : {... .., M ., ,.:„.:..7..Y,.s.-.r�.. :z.:-;�.�, 4 .�.;., r.t, r 2Xrx�' .a».:°*�t r.. ..A •r'�:-�'� _ �iTY. .. ... ..7��f �G4. ,a.,..k"a��.�.y''�.`.�� .*.,u-;.