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HomeMy WebLinkAbout0341 SCUDDER AVENUE - Health I�VWSCUDDERAVE, HYANNIS 7 A = 288 081 i 1 u Commonwealth of Massachusetts "el 09- O� - Title 5 Official Inspection Form (e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name/ information is required for every Hyannis ✓ Ma 02601 3/2/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �f.�yr /5 a�t(o filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Betdan Lane VQ Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3/2/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The property located at 341 Scudder Ave. Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon precast leaching chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): Ei 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 FIND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments MM e 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owners Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � �/ 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: system installed 6/13/2007 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: El 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list ye age:g years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7 IBM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I.� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: 2x500 gallons ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching facility consists of 2 precast leaching chambers. Chambers were video inspected and found dry with no signs of past overloading. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M e 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 `LI_TT_1 O pr� t5insp.doc•rev.7Y2612018 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page.. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 341 Scudder Avenue Property Address Patricia E. Ciervo Owner Owner's Name information is required for every Hyannis Ma 02601 3/2/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 -4-3Lo TOWN OF ARNSTABLE OCATION �t= ec Ky a SEWAGE# ZW7-Z3S' VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 3C c- SEPTIC TANK CAPACITY ,566 Vic,`\or, LEACHING FACILITY:(type)2.-�OU QG.\6A e 6(size) NO.OF BEDROOMS OWNER ""'e. 16 PERMIT DATE: G'I-®7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 1 LA A -7 i3 L 3Z c °' ° . �3-23 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication r igio l 6p.5tem CongtrUCti0ll Vermtt A i 'on for a Permit to ct -) Repair Ur)e Abandon ❑Complete ,—� P P ('') Pg O O p System UIndtvtdualComponents 0I� � Location Address or Lot o...`2 7.�J`�'�,�J " �t Owner's Name,Address,and Tel.No. - / - b Assessor'sMap/Parcel �� ��j ��i;�„ �J, Installer's Name,Address,and Tel.No.Lr'. ) Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms � Lot Size sq. 8. Garbage Grinder (4p 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 571P Type of S.A.S. ; G Kt- Description of Soil Nature of Repairs or Alterations(Answer when applicable) n- oH� �,r,d �� j f/ is A clif 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 Envi ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He . 7 Signed _ Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. XO 7— a 3 Date Issued 0- ._;�';,..: . .. i » _.._;�. ' 1,a ._.w-y„ ?+3a,.x^atad. ^�,.. ', „are ..... .r. '. �!h»'d:�1'Sr'� .:,,.•, .. �L:. , Fee /v v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION . TOWN OF BARNSTABLE, MASSACHUSETTS Yes 3y� , 2pplication for Oaf 6 Mem, Congtructiou Permit ,d �- � _ App'li ti�a on for a Permit to � s ct. ) Repair( Upgra e O Abandon O ❑,Complete System Zndividual Components Location Address or Lot o.a 7S��`� "` Owner's Name,Address,and Tel.No. Lt/� `! e-m c Y�z ' l 4 6?hn! I� Assessor's Map/Parcel 4 ' �$/ Installer's Name,Address,and Tel.No.f�T Designer's Name,Address and Tel.No. / s�g vj 4.1g9 6. 177 l/s. ten- . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( 11P Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required) gpd Design flow provided gpd 4 ..Plan Date Number of sheets Revision Date Title LL Size of Septic Tank l Type of S.A.S. U Description of Soil \ •r Nature of Repairs orA_lterations(Answer when applicable) I r/oKJ �'x �rr!s j a19tiG sy A C"I ,. (J U✓A� f r l e✓/! tti//1 Cy/l 1 !y e�u1� /5�10 �i C.. f l /d �id�/c fcf✓� �j a'> C' 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 Envi ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He / Signed t Date Application Approved by ow- Date Application Disapproved by: Date for the following reasons Permit No. �Gy- 7 ` �7 a S Date Issued 7777—y.. 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 / �.l111-J), 611-0 7` -rl us at �rp vrJ�/ ��>, 1Aa,7,9/) has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No. ;too7'Z 3 S/ dated // '7 L� ---- , Installer ��'. o/"�r Cy�J�"y,,��� Designer #bedrooms Approved design flow gpd The issuance of this permit shall{not be construed asaguarantee that the system will functi n as designed. Date lf! ! Inspector --------------------------------------------- No. � � 7� Fee 145eJ— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwigoat *pgtem Construction permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at J-7-5� �lu�✓c1-� ✓+ ,/e��, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/h�er�'duty to comply with Title 5 and the following local provisions or special conditions. ♦k" Provided: Const cti//on must be completed within three years of the date of this ermi Date (dam Apnuvedby1 1 J, A�7 [t ,fig r115 G„ 9 r Iry STC//4. iIACOy'e ��v� 7 57 if UC C Town of Barnstable y o� Regulatory Services * BARNSfABCE, Thomas F. Geiler,Director 9$A 63. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 30, 2007 Ms Evelyn Nemetz 275 Scudder Ave. Hyannis,MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located ate Scudder Ave, Hyannis, MA was last inspected on April 12th, 2007,by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic.system showed that the system"Failed" under the guidelines. of 1995 TITLE 5.(310 CMR 15.00) due to the following: 80% of the septic tank is under the garage. Recommend new septic tank be installed. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable. Health Department. BARNSTABLE HEAL DEPARTMENT Thomas A. McKean, R.S.,C.H.O. Agent of the Board of Health _ CO-VIMO_NWEAI,TH OF?�LAf SSACHL- � SE.-r:.I-S E-3ECUTIVE OFFICE; OF ENVIRONMENTAL A.F_ DEPARTM >J E_VT O EiN vzROly� =� IEN 'AT pRCT_,_C` p 1^'I a -8 Z. o � TITLE 5 OFFICIAL INS PECTIOi\FORM--NO T FOR VOL LNTT RY ASSESSArE NNTS SUBSURFACE SEIVAGE DISPOS-AJ SYSTEM FORIJ PART A CERTIFICATION Property address: o2 �-� SC 4 d/o ,4vL Owner's Name: �je-k47 e Z Owner's Address: oZ S H -(WO.— Date of Inspection: 01 L O/ v /oL p / Name of Inspector:_JPIease print)2Vc Company Name: iliv/ — C Nailing Address: p p,)C Telephone Number• ,gyp$ _ CERTIFICATION STATEMENT -' I certify that I have personallv inspected the sewage disposal system at this address and tat Yz below:s true, accurate and complete as of the time of the ' ` inspection.The inspection was r,. -or-e f" training and experience in the proper function and maintenance of on site sewage disposal s vste.J�Z am a DLP approved system inspector pursuant to Section 15340 of Title 5(310 C1IR I�_Opp� The cz.s-?T__. - _{ Passes tionally Passes _Needs Further Evaluation by the Local Approving_.ut e t Fails - Inspector's Signature: , Date:._46 */ � the system inspector shall submit 1 a copy o_this inspection report to the Approving Au- o t.;(.8 pa d o F DEr)within 30 days of completing this inspection.If the'system is a shared system of has a desi J, __o ,-o= n.j J)gpd or greater. the inspector ,and the system owner shall submit t DEP.The original should be sent to the s stem owner he report to the ap_ op�a,e regional o_z o ,he. author ty. tL Y d copies sent to the Mc, if applica'•.:.le. a_d-,he a_ - `otes and Comments Re Cv M r•7-e n c 4-e SQ �[ . /eve �o hs 4h .�e7� 6.► �s B """"This report only describes condition or use a s at the time of inspection and under the conditionsn - time.This inspection does not address how the systemiIl perform in the future under the �that at conditions of use. the same or ffe dig rent _Title 5 Inspection Form 6,11512000 na cra 7 Page 2 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNT_A-2Y ASSESSZIE�--TS SLBSLWACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORAT, PART A CERTIFICATION(continued) Property Address: O Owner• /v e(Mf- Z�7�, Date of Inspection: �d Inspection Summary: Check A,B,C,D or E/AL_N S complete all of Section D A. System Passes: /r I have not found any information which indicates that any of the failure criteria des cr : i 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. bee rn J 1 CtiiR Comments: B. System Conditionally Passes: KOne or_-more system components as described in the"Conditional Pass"section need to be r l �e . repaired. The system upon completion of the replacement or repair.as Health. d ep approved by the Board of Heal_h.will pass. Answer yes;no or not determined(Y;N,'ND)in the for the following explain. statements. If"not dete_,rrined"please — The septic tank is metal and over 20 years old.*or the septic tank(whether metal or not) is s-UMrall unsound,exhibits substantial infiltration or exfiltration.or tank failure is imminent. System will pass inspecr;'o 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 CoL�liance indicating that the tank is less than 20 years old is available. NTD explain: 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(:, th approval of Board of Health): - broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pass inspection if(with approval of the Board of Health): T p'p`''j' I :4 broken pipe(s)are replaced obstruction is removed NTD explain: T41. Tn cr�nntinn T,'n+-w �/t V711/1!1 - - Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLL7.NTAgy ASSESS���-TS SI�BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORI,F PART A CERTIFICATION(continued) Property Address: 09, C -1N1 Owner:_ CIA- Date of Inspection: C. Furtvaluation is Required by the Board of Health: G' conditions exist which hich require fiu-ther evaluation by the Board of Health in order to dete—tee.if:he syste-_; is failing to protect public health, safety or the environment.. L System will pass unless Board of Health determines in accordance with 310 C TR 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 rnarsh 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 w thin 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.rater supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water slip, ,IV R eL _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 f et or more=om 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 col;for* bacteria and volatile organic compounds indicates that the well is free from pollution from that fa,,;ut<-and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p m_ provided*_ -- - ei failure criteria'are triggered.A copy of the analysis must be attached to this fo1-j,p I a:_o o;h_� O �a� -74C_ � � � s (41-7 � 3. Other: ,(T G �d� 7'O✓' �Gt/ ,Sp��lG G e7 A=le*-c.j4t�h (ter wm v Title { Tncncn4inr L'n+-... L/1 Ci�n.,.. Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLLTN7ARy ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTFM II�SPECTi© - ©It�I PART A CERTIFICATION(continued) Property Address: G'i.✓t dl� Owner: Date of Inspection: 1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the followjng for all inspections: Yes cessDool �iDischarge ckup of sewage into facility or system component due to cverloaded or clegged ^.or ponding of effluent to the surface of the ground or surface waters due to an overloaded or �ogged SAS or cesspool tatic liquid level in the distribution box above outlet invert due to an overloaded or clo??ed S AS or -eesspool -- iquid depth in cesspool is less than 6"below invert or available volume is less'than'2 day flow- Required pumping more than 4 times in the last year NOT due to clogged or obstnT;red pipe(s).Number f times pumped ( AHony 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 tribe art-to a surface water supply. any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. c/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet tom a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm4 provided that no other failure criteria //' are trigg � ered.A copy of the analysis must be attached to this form.] "V (Yes/No) The system fails.I bave determined that one or more of the above failure ':-eria -i si as described in 310 C1v1R 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 gPd• flow of 10.000 gpd to 15.000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es o the system is within 400 feet of a surface drinkir.Q water supply — the system is within 200 feet of a tributary to a surface drinking water supply the system is located ' a nitrogen sensitive area(Interim 1'ellhead Protec,on Area—itz _�} o-_ _�__` Zone II of a public water supply well -_ if you have answered"ves"to any question in Section E the system is considered a sl-- ticar_t`hied; or "yes"in Section D above'the large system has failed.The owner or operator of any Idrae ejatem een, significant threat under Section E or failed under Section D c 15.304. The system owner should contact the a hall upgrade- ` d` _ „the system in acecrda-ce ,_tt ; appropriate regional office of the De i partuzent. Page 5 of 11 OFFICIAL INS PECTION FORM-NOT FOR VOLLr4TAzRY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENT E SPEC'TIO` FORA? PART B CHECKLIST Property Address: cz / ✓ C''-fin/ �� Owner: /VeWI_ Gi 4 / OoZ(oO� Date of Inspection: Check if the fo'lowing have been done.You must indicate"yes"or"no"as to each of the follo-vI ng: Yes/CTo (� 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 v — Has the system received normal flows in the previous two week period? v Have large volumes of water been introduced to the system recently or as part of this in-spec—ion ✓— Were as built plans of the system obtained and examined?(If they were not available note as 1rA) .Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for sans 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 condir_•on 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 nroueT maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue is unacceptable) f;10 CI MR 15.302(,)(b)] ap�raxii-rarion of d-'ance ";tlo jZ Tncr�ortinnnrr Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOL LTIN ARy ASSE SS_A TENT SUBSURFACE SEWAGE DISPOSAL SYSTEM g s�re���,. .�oR� S PART c SYSTEM INFORMATION Property Address: �J �,�e/2v ��✓ �I do2 60 Owner: egg Date of Inspection: /d D FLOW CONDITIONS RE SIDENTL�I, \T unber of bedrooms(design):--?—. Number of bedrooms(actual): DESIGN flow based on 310 C-R 15.203 (for example:110 gpd x of bedrooms): 2-?0 Number of current residents: Does residence have a Barba e g grinder(yes or no):/f�7 Is laundry on a separate sewage system(yes or no)Avo Fif yes separate inspection required; Laundry system inspected(yes or no): /K Seasonal use: (yes or no): Water meter readings,if available(last 2 vears usage(gpd)): SUITIP Pump(yes or no): /1/0 Last date of occupancy: �i t4 rr'-4— COA-ZNIERCI_a,L/INTDti STRIAE Type of establishment: Design flow(based on 310 C_4R. 15.203): apd Basis of design flow(seats/persons/sgf,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GE\'ERAL IVFOR'�IATION Pumping Records Source of information: /gyp 41k& e c/ �f Was system pumped as part of the inspection(yes or no LjyV If yes,volume pumped: gallons--How was quantity pumped determined?. Reason for pumping: TYP F 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 ccn-act obtained from system owner) ;to Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all components, date installed(if Down)and source of information: S Ozood Were sewage odors detected when arriving at the site(yes Or no): T;tla T»enort;nnG/lnnn Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLI,TIN CRY ASSESSA.EATS SUBSURFACE SEWAGE DISPOSAL SYSTEIM I\TS'PECTIO\FOR_11 PART C nn SYSTEM INTORMATION(continued) Property Address X� if OR-ner: /V Date of Inspection: �a2 BUILDING SEWER(locate on site plan) Depth below grade:_ � 'Materials of construction: ast iron _4✓0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ ate on site plan) Depth below grade: o� -Material of construction:_ oncrete__metal_fiberglass_poivethylene _other(explain) y If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach z cony of certificate). SX � -- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: es Al Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottoms 0 outlet tee or baffle.- How were dimensions determined: Comments.(on pumping recommendations;inlet and oe6et tee or baffle condition_.strucw7al iniegnts liquid ievei, as lated to outlet invert; evidence of leapae.etc.): ate W GREASE TRAP: locate on site plan) Depth below grade: Material of consti-action:_concrete metal fiberglass_peiyethyiene other (explain): - Dimensions: Scum thickness: . Distance from top of scum to top of outlet tee or baffle: Distance from bot=om of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition. structural date as related to outlet invert; evidence of leakage,etc.): ` - Page 8 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOL€TINTARY ASSESS_'�TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART C SYSTEM I/NFOROVIATION(continued) Property Address: t✓D� !/e_ Owner:APky?f r Date of Inspection: d TIGHT or HOLDING TANK:N (tank must be pumped at time of inspection)(Iocat ,on site Dian) Depth below grade:. Material of construction: concrete metal_fiberglass_polyethylene other;ex'L lain is Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: . y Comments(condition of alarm and float switches,etc.): DISTRIBliTION BOX:Z(i�f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 0/(4 4 L Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any ex-::deuce of leaka�o,g into or out of ox. etc.): 50X .e�e� so/i� /ya PL VIP CHAMBER: /y (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber.condition of pumps and appurtenances; etc.): i Titlo Tncnnntinr rnr �/7 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLLTINT4RY ASSESS-AIEI-TS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTI©N ORAZ PART C SYSTEMI1�TFORMATION(continued) Property Address: c�,s yr J�� iQlip� Owner: v W Date of Inspection: Q SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type — SOO G�vh leaching pits, number: 1��./// f leachinb chambers.number: r / leaching galleries,number: W leaching trenches,number;length: �l 'v ISO_ 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 veceta on. etc.): vie c v► p, (�f a vt czI.,C-j f CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) \umber 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of °ege-taron, etc.): PRIVY: locate on site pla n) n) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil; signs of hydraulic fail_nre,'level of ponding;condition_of t ecret= T;tln G T»c*.ci.tinn T-nrry, �/1:!'lnnn ' Page 10 of I 1 • OFFICIAL INSPECTION FORM—NOT FOR VOLUL NTT_A-RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAAL SYSTEM INSPECTION FORNT PART C SYSTEM INTORMATION(continued) Property Address: s- Owner• Alle Date of Inspection: /d. 0� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage`disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all «ells wit o P earl._ h_n 10 _0 feet.Locate where public water sup enters the buii_amg. 6, /V Ga�a�Q Ca T41. c Tnc*cnr;nn ,,,, �n v�nnn an Page I 1 of 11 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY' ASSESS- IENT.S SUBSURFACE SEWAGE DISPOSAL SYSTEM J_SPECTIoN FOR_�I PART C SYSTEM INFORMATION(continued) Properh Address: C2 91T 1.5c� ��/J� Date of Inspection: SITE EXA-M . Slope Surface water Check cellar Shallo«-wells /7o Estimated depth to ground water �pZ feet Please indicate(check) all methods used to determine the.high ground water elevation', Obtained from system design plans on record-If checked;date of design plan reva'-ewed. 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 Mcnibe how�rou established the high ground water elevation: �^ �f ,-- Tiv /d ' /li "'o o c G�LG a•, oY .o ti i' "//Gt/ o2T• ' • �o n e- — OWN OF BARNST�AB/ LE F-ZATnI( N v�� ✓l SEWAGE # & VILLAGE .�'`� ti�' S f_ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) '"`" `� "Z �- '(size) NO.OF BEDROOMS .3 BUILDER OR'OWNERPERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tab to the Bottom of Leaching Facility Feet Private Water Supply Well and aching Facility (If any wells exist on site or within 200 feet eaching facility) Feet Edge of Wetland and Lea ng Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - f r 0 t it v i , 1 t 3 �"N � '� � f ' `�• Fee$5 0 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Miopooaf *pgtem Con!truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. jtj I Owner's Name,Address and Tel.No. 1275 Scudder Ave. , Hyannis George & Evelyn Nemetz Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Servic P O box 1089,Centerville Type of Building: Dwelling No.of Bedrooms 3 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 Type of S.A.S. Description of Soil B a n d Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and 2 concrete chambers with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by_ i o of Heal Signed Date Application Approved by /GbDate Application Disapproved f r e following reasons Permit No. Date Issued TOWN OF BARNSTABLE 5 LOCATION _� r �c v��t✓L (/ SEWAGE # 6L("X -6 VILLAGE ASSESSOR'S MAP & OTIke INSTALLER'S NAME&PHONE NO. K6 -2 Sr -2 % Z SEPTIC TANK CAPACITY 16-0- 0 LEACHING FACII rry: (type) �"''s"r �l `Z L.L (size) NO. OF BEDROOMS J BUILDER OR OWNER /L/L%✓�JC/ �� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tab to the Bottom of Leaching Facility Feet Private Water Supply Well and aching Facility (If any wells exist on site or within 200 feet eaching facility) Feet Edge of Wetland and Lea ng Facility(If any.wetlands exist within 300 feet of leaching facility) Feet Furnished by � a i .tr - F No. A/no-66 Fee$5 8 THE COMPONW.EALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DI I TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for izpogar *pztem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Aban�on( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 275 'Scudder Ave. , Hyannis George & Evelyn Nemetz Assessor's Map/Parcel f') Installer's Name,Address,and Tel.No. Design' s�Name,Address and Tel.No. Wm. E. Robinson-Septic Servic P © box 1889,Centerville Type of Building: Dwelling No.of Bedrooms 3' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures -f`. Design Flow gallons per, ay. Calculated daily flow gallons. Plan Date Number of sheets/ Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Saner l Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system r .,consisting of a D-box and 2 concrete chambers with stone _ all- around. Date last inspected: } Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance,with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o of Heal . Signed- o F' a k,9, Date Applicatio&Appr ved by r, w Date o`Application Disapproved f r e following reasns F i T Permit No. *,, J Date Issued THE COMMONWEALTH OF MASSACHUSETTS Nemetz BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 275 Scudder Ave. Hyannis has a nstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ted V . Installer Wm. E. Robinson Sr. Designer I The issuance of this permit h 1 t e construed as a guarantee that the system will function a designed 0 C , Date Inspector '3 M A --------------------------------------- ,m► No. Fee 5 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Nemetz lizpotal *p$tem ConstructionPermit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 275 Scudder Ave. , Hyannis and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the ollowing local provisions or special conditions. Provided: Constructio st be co pleted within three years of the date of pe t. Date: Approved by r M• if 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) ), Witl iain E. Robinson,s�eby certify that the application for disposal works construction permit signed by me dated r/�� b'' �� , concerning the property located at 275 Scudder Ave. , Hyannis meets all of the following criteria: • The failed system is netted to a residential dwelling only. There are no commercial or business uses associated/ the dwelling. The soil is dassifi as CLASS I and the percolation rate is less than or equal to:5 minutes per inch. There are no within 100 feet of the proposed septic s)stern — There are no p ate wells within 150 feet of the proposed septic system There is no i ease in flow and/or change in use proposed • There are variances requested or needed. • The m of the proposed leaching facility will n t be located less than five feet above the maxim adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor meth when applicable] • If a S.:3.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed t thing facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following; A) Top of Ground Surface Elevation(using G1S information) 1 B) G.W.Elevation +the MAX. High G.W. Adjustment DIFFERENCE.BETWEEN A and B SIGNED : i i ( ✓ DATE : [Sketch proposed plan of system on band. y:hnith folds:cm . f I 1, _ .` w� � � � l 1�� I R J � `. ,. 7 LOtA"T10N SEWAGE PE MIT NO. VILLAGE INSTA LLER'.S NAME & ADDRESS v BUILDER OR OWN R I DATE PERMIT ISSUED � . :.. DAT E COMPLIANCE. ISSUED I a . s .Y IN00 t No.79-. ....... Fss........ . .R �..... THE COMMONWEALTH OF MASSACHUSETTS .BOAR® OF HEALTH ......... .....Town..---.---.....OF..............Barns.ta.}ale-----------.........---------------••----- Appliratilan for Dispoii al Works Towitxnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an. Individual Sewage Disposal System at: ...2.7.5...acudler...AmP_ .Hyann z-,... ar............ .................................................................................................. Location-Address or Lot No. ....QeQrZe.. Me mat 7................................................. .2.75.---- cudder-- nis.,...Majt.......... Owner Address ............................... 128_..Bishops.--Terrace Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms...........Z..................._..........Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons..........2........__.__.. Showers ( ) — Cafeteria ( . ) Q' 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. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . LL; Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................... •------------------------------.-----------------------------------------........------------.....•--......................................................... 0 Description of Soil............S--and..............................................................----------------.--------------...---.........---------•-•----•------------------ x •. ----•--------•... . . . ----------------------------------------•-------------------....-----------•--------------------...------ Nature of Repairs or Alterations—Answer en a icable..j_ a. t- �___ ,�_._ 0_0..ga,J lon..:. Septic -Tank and a 1,000 ga on 'Leach � $oh pac i � -------------------------------------------------------------••--•...-•--•-•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the boar f ealth. Signed.. ....... .-• - ..... 3,12.31.79-_-... Date Application Approved By = 31 z_3179. Date Application Disapproved for the following reasons-----------------------------•--•------------------------------------......-----...............•....._.....------ ....---•-----------------•--••-----------------------------------•-------...------------------------...--•-•-----••-•••-•••••---•••-----•-•••-•-••-------••••--•--••-•-••-••--••-•-•••------•-•••-•-•-•- Date Permit No-----79.=......................................--.... Issued..:...----3/2 3/7 9 Date THE COMMONWEALTH OF MASSACHUSETTS �O�lRD'.. OF HEALTH ................Town..............OF............... a rZifl .,6bla........................................... Artlira#flan for Wvtt1 Works Cnnnxnr#ittn eutif Application is-hereby.made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System 0 dd f --- t O Location-A dress Scudder Ave Lot N ann j S a+ ,,LLB"}eY�................................................ _. b • 1 ! d Kt y z Y i Owner Address w _�z_ Q_o� in Bi pp4gp5...Zerrace 4 Hyanfiis................., a 'ter Installer Address Type of.Building Size Lot.._.. ...Sq. feet U v.p�ru Dwelling—No of Bedrooms...____..__2..............................Expansion Attic ( ) Garbage Grinder ( ) aOth Type:.of,-Building ............................ No. of persons...........2.............. Showers ( ) — Cafeteria ( ) da Other fixtures .....-•---........•••••-•••-•••••••....•••••••••-••......-----••-•-----_... ........•••• W Design1'low }:> :,. 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..,-, t � sq. ft. 3 Seepage ,Pit,Not..`..:. -........ Diameter.................... Depth below inlet.................... Total leaching area.: ....sq. ft. z OtherIIV&ribiYtiori box ( ) Dosing tank ( )., y' a Percolation Test Results Performed by.......................................................................... Date..... '= ................ a", nsra.tKa'< ,.a Test Pit`No l ...............minutes per inch .Depth of Test Pit.................... Depth to ground water.......................... f=, TestPit`No 2........... per inch Depth of Test Pit.................... Depth to ground water......................... P+ ......................•••-----•.........•--•-- ------_..... r lt�K•r _ ................................................... O Descr ti n of�;Soil .PATid .......................................... x --_-•--- ••• -- ....................... W UNature`of Repairs-or Alterations—Answer when a pl cable_ _ pt!c Tank and a 1,600© gall �,�ac�i --------------------- - ---- ---•••-• • •••-- --............................................ Agreement: Thee undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prov�isioiis:of'TTLz 5 of the State Sanitary Code -The undersigned further agrees not to place the system in operatiowuntil a Certificate of Compliance has been issued b the boar L_eal.th. z. Signed.. .... .: ...... : '......... ...... at ApplicationrAPproved"`By-•-••----•-•----•-------------------•-----_-_______----=----•---•---------......--••-•-••-•-•--•- . � �17 ..... 3� _'.: " ' Date Applica> k6ri'D'sappr6ved.for`the following reasons- ------- ---------------------------------------••-•-•-••••••---•- ---•••.. '------......-•----- 9 7 mh5 S t a , Date s F'erriii6No-___--79 �1I J� g .. Issued_....... r Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ............................ Ttn o ..oF.........: a x St.ab?e .................... ... ,.: . r.. •. �. <. , .. ��h5 Sark •:'.. (Infif irat e of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Re rr +a+ by l�. = i 1._.. �,�� .ce.,.. . : _. 34 ho x'r ce,...I raizn .....................)jr ...................... 1 Installer at ys ...p -:.. -•----G�� _..H...__'nemet2 has beem�,Installed -n_accordance with the provisions of TITLE 5 of//The State Sanitary CoAe/ lg ibed in the ...application for Disposal Works Construction Permit.No........ ..... /A-__ .......... dated---------_._._`'.77..//...._...................... '4l THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR E,THAT THE l SYSTEWI WILL FUNCTION SATISFACTORY. DATE.... , Inspector......... .-•-•- ....... _..---_- THE COMMONWEALTH OF MASSACHUSETTS ltvi BOARD OF HEALTH . 5 C rt `aq 13. x°xta�taabl aS,O(1`/I ...................l 'wn....OF...... ...................................................................... ......."�a,..��?../ FEE..,x ......... No ��is�rrr��� nxk� �nn��xnr�Uan px i� A Fc 3 Cese ool Sar�ices $ ishops Ter. , Hyan s ni Perm>ss>on`is hereby granted •. ........... •-•-------- ------------------- = ---------....... -----._..................._._. to Construct (.,,) or...Repair ( X) an Individual Sewage Disposal S st �'@�!�'� at No...? 5ctiidp -AvP.,..,... unnie -- Expor�e ' �. g J �7 n X 1�7{�Street !9� e ` 3 1 G J.( (3 as shown on the-,application for Disposal Works Construction Pere No/.�f : Dated 7 0/ Board of h DATE.... 77 ............................... FORM I 55,,.HOB•BSt`& WARREN. INC.. PUBLISHERS