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HomeMy WebLinkAbout0411 SCUDDER AVENUE - Health 411 Scudder ve 288-137, West Hyannisport 0 i 5 ° �I 1 C;L Lod Commonwealth of Massachusetts / "/ ✓I ITO t,,S� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address Owner Owner's Name / C� information is lj Or CA 9 [ required for every — page. City/Town State Zip Code Date of Ins ection 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. CO Important:When filling out forms A. Inspector I mation on the computer, a r. use only the tab key to move your Name of Inspector cursor-do not ,�_Allll O use the return Company Name key. gy Company Address zFAS '/ y /�^ State Zip Code r City"ToSo oOPT ' Telephon'd Number 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 15.000); 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 maintena of on-site sewage disposal systems. After conducting this inspection I have determined that the s em: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. Fail aig � Inspecto 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.7/2 612 0 1 8 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r33 �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v Property Address Owner Owner's Name information is I/ M�. ,may required for every e.4 a 1114414 Oar / cra(0 9 page. CityPrown 1 State Zip Code Date of Irbpectidn C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) Syste asses: 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: 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts ,e Title 5 official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 11 Owner Owner's Name information is l A required for every S� av11/1 J. 0 page. CityFrown State Zip Code Date of InsiJectiont 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): ❑ 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): 5 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.7/26/2016 Tide 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r�cu Property Address Owner Owner's Name information is es L u`An4l�Do�_1— Oa/ 9 Q a D required for every T I, 1 T k / page. City/Town State Zip Code Date of In ection 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: *k 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � ) Owner Owner's Nam information is Uo / - a /�,/ required for every //77 page. City/Town State Zip Code Date of Inspe tion C. Inspection Summary (cost.) 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 ❑ L_�/ Liquid 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 obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Te"', 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 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 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 f Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SC Avo, Property Address Owner Owner's Name information is p� �� �"� ^ �0 required for every poonuhfp d� page. City/Town 11 State Zip Code Date of I specti n 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 o ❑ umping information was provided by the owner, occupant, or Board of Health Elere any of the system components pumped out in the previous two weeks? El as 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 i, P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y SC � �v Property Address �. Owner Owner's Name S information is �-1 required for every `�" �'s Gi U{1�� /J VD 6 /,;L P$ Oti0 page. City/Town State Zip Code Date of InsP ction D. System Information #0erM I _C?'_ gv 1. Residential Flow Conditions: --- ' - 3 Number of bedrooms (design): _ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �1�0 Description: / 5" &'&� � fG � N 4.1 ♦a T[�H 46 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes El No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes 9?'No Laundry system inspected? ❑ Yes 2-*%o- Seasonal use? ❑ Yes ;-4-No' Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? e ❑ No Last date of occupancy: )4Da t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts g Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L � 4ve, Property Address , Owner Owner's Name information is �� �� required for every page. City/Town State Zip Code Date of Ins ction 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 PIG If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — t5insp.doc•rev.726/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - of or Voluntary Assessments 1i c w 4ve, Property Address i+ Owner Owner's Nam information is required for every page. City/Town State Zip Code Date f Inspe tion D. System Information (cont.) 4. Type of stem: 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 gfTnponents, date installed if known)and source of information: Ala C; Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructiZ4O El cast iron VC ❑ other(explain): Distance from private water supply well.or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form �n iI= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments &4 Property Address . Owner Owner's Name information is A#4 n 1 fB /`� / V i'�/�/�, of k 7�required for every O page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Material 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: - 110 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness S� Distance from top of scum to top of outlet tee or baffle - — Distance from bottom of scum to bottom of outlet tee or baffle -0 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.): t4 011114 1 11e�' / awl,. a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts �yIF Title 5 Officia l ns ecti on Form lia Subsurface Sewage Disposal System Form -N. t for Voluntary Assessments u Property Address 541-11 Owner Owner's Name i required for every nn ll nformation is / Q A W/ / 6U 6 /� page. City/Town State Zip Code Date of Inspfection 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.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name/ / information is W�s� &6441f'00J_ A/+required for every d'lv page. City/Town State Zip Code Date of Inspe ion 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 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.): sok S vu i t5insp.doc•rev.7126l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 III Commonwealth of Massachusetts �. o� Title 5 Official Inspection Form <II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / Ave Property Address Owner Owner's Name information is e-4 H 902- q a �-o required for every page. City/Town State Zip Code Date of Insp ction 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: / Ti�7 / /tI � ✓� �� J� ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: —-------- t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l ScN 14vt, Property Address Owner Owner's Nam information is 1 /n 1 11nect—ion' required for every (A q N d If n op1� /offpage. City/I own State Zip Code Dte 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.): _ate _ l (4 Gil �N� t 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 f Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address S � Owner Owners Name information is /Lf required for every e 1 / /,/+ page. City/Town State Zip Code Date of nspe ion 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 I Commonwealth of Massachusetts 19 Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address Owner S4��Il Owner's Name/ / 11 /� required for is every t/�/?S T 6aAslivo," /A 0 a� re wired for eve __ page. City/Town State Zip Code Date of Ins ction 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 nchmarks. Locate all wells within 100 feet. Locate where public water supply enters Zan Checkone of the boxes below: etch in the area below attached separately "Oe t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 -------------� --� '�----' -------- -' -'^----- .........-/... ..... ...- ....- ......-......---- ....- ... ----� ----- -�� -- . � ! -------'------�--�-------��----�---' ---------------�---------------..�.... ....... ...............-................ ....... ---'---'----!--- . TOWN OF BARNSTABLE ASSESSORS MAP& LOT INSTALLER &PHONE No. NO,OF BEDROOMS BUILDER OR OWNER I COMPL LANCE DATE: SeParation Distance Between the: Edge of We-tiand and Leaching A MIS- Facility(If any wetlands exist. within 300 feet of leaching facility Furnish _Feet ======,.=======, =====.,,`�=======.. =============='�===-====�===, � �� -' ----�------'---- --'-'���-- -----��-�------� ------'�-------- -------���----------------------- �---'----�---' -------'�-'-------------'��-------- ' --------------��--_'---' -------�.. �'------'�---' � � � � � ' ! � � � ! � � ! ! �� !! . =..=.......=...........=..====,�=...=........�~=~. | . � | ^^''^^^^'''!^^^''^^^^'^^ ''^^^^^~^'=^'=^^=^'=^^�=^^^^^^^'^^^.^'^^^^ -----����------- ---------------�i-------��---' � �� � � ------- -------- -------'-------`--------�---' �------��------- ---------------.�----��-�-'. � - --� . �---' �-------�.�-------- ---------------�--------.---' ------�-------���........-......-- ------------�--���----...... --�--' ...... --- ---------------��--------�---' ` �� � �� � --- ----^--------------�- . � �`--�-----'�---------------'---------------���-------------------------------' -- -------'� � �-----------� ---����--------- -� ------------.-----�-''---- -���-''�----'-------------�--�-------- --' W7S .AME& -------��--_-----------'�.--------�----- ---------�--------�-------`--------� --�-' ---------� .-� -----'� --' -------'-------------- .`-- ... .......--------'L-------�i-------i�-----------------------.i-------'i --' � �-' ----`-� -----' ------``---- ---��---------------`---------------''---_---'---------------'.---- --' U . ' Commonwealth of Massachusetts Title 5 Official Inspection Form �5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Co _ _ LI- - Property Address Owner Owner's Nam information is Y� / ^p required for every `'y P's �+�� f �`� 91 page. City/Town State Zip Code Date of Inspec on D. System Information (cont.) 15. Site Exam: ❑' Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: a 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 tr local Board of Health-explain: l� f L f A/ ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must escrib`ho�m you established the high ground water elevation: J go le 5 Co. C/W C.40,L 640f 0 / ... 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 iI e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ave,- Property Address Owner Owner's Name information is opecti required for every page. City/Town State Zip Code Date of I E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: P A. Inspector Information: Complete all fields in this section. ertification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, r 5 completed as appropriate 4 allure 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ., , Na l tree. "a 5 0.0.1:" THE COIN1V�O"EALTW OF MASSACHUSETTS /� Eatimd in cc°rnputer.— PUBLIC HEALTH QiVIS#©N . TOWN 4F BARNSTAOL.H,MASS�CHUSEITS Y�g .. Application for a Permit to Construct(, ).1 gair( �l pgradc.( .)Abandon( ) ..I CompkeI Syy mi ��individua[Cumponeitts . .. .. I.ocaiiun Ail tress or Ltit tro. 41 1''.. S c udd er Av.e Owner's.Name,Addmss and Cet N6. 7 7 5—5 7 2 2 W lyann>,sport David Still 1?0 Box 323 .,4ssessoi's-tvtoplt'areel �, lnj Hy.anni sport,, ..INA 026.7?, _._. _ �instulter's Nnnre..Addre"ss,.and.'Cei,Ya: 7'7 5= 7 7$: Designer's.Name,Address and 7oi>:No.. .: VIM E Robi:nson, sr Septic tv PO Rox. 1089 Centerville hmA. hype of Buildinga: Dwelling WofBedrooms 3/4 Ut—Size�sn;f't'. GarbageGrindcr:k�o) Other Type of Building No.of Por.ions_ Showers,( ):Cafeteria.( ) ' Other:Fixtures..:... ..— .... ..... .... _.. . . .—...._:... . ... ..- _ Design k'to�y: gallons perday. Calculated daily flow: gal;Ions. .. :Flan'Date_ .. . . Numbdr of sheets: Rci i5ion Date: Title . . . .. .. . .. Size.cif Septic.Tank Tyj> of S.AsS 13esrriptinn of So! sand .. __ . . .... ... ... .. ... _, .. .... Naiure of Repairs or Alterations(Answer when apphc...e)T ,S1)St_1 1 !t j t 1 p..5 GPI j in system consisting of 1500 qal tan>k D-:kaox and 4 stodepad ed . " R-20..in''iltrators Id , . Date last inspected:. :: .. :.:... ............. :. ::C: Agreement. I'he undersigned agrecstaensure the.eonstruction and maintenatice;of the afore de.scrib d an site Yi,v zige:disposal:system ii accordance with the provision of Title:S of the Env iranmept3I Cock,and not to rn tee the system in 11 0ation until a Certifl ate of Catnpliance has peen issued b is and of Heal4lt. � Signed ° ✓ Date Application Approved by Date . ' �' ^ Apphcatim Disapproved for the fnllow,ing reasons. _.. .... .... i'etmit No, :. '" Dnte.9.med c'?.. .. ° "..... _..... ....I ... x = =r= "" x = eaxa^exrsy^�� -mom c� i _ THE COMMONWEALTKOF MASSACHVSETTS� m t x l B Rks,,I ka`MASSACHUSETTS ertcfxte. Of ry.CampCcance INt51S TO CE 71 ;that the On s e Sewage Dupnsl;t System t o iatructed( )Repaired 't)Upgraded( ) aY Mkb en ctantitauctedin acLtndance vj11" Orr p�aYtstons ofTatle 5 nn8 thefarDisj}nSat Systdtn Can`siruction 7ermtt Na, r dated " ^^ idttt C R , rit`sc rsri. 5r 9 la.' S'r InsiaJler Destner Ttie assvatn a of flats permai shall:nat Ize caitstrtui as a guaranice thai the system�wt`L.t't Herron' cstgn d llgte _, , tnspeetar. ��+ " �� .....: _:: ..... :.:. .. .. .. S T,HE C(iA9MON?NEALT}3 OF MASSACHUSETT5 i 1.I � i>� C ���t -10. Can tructtvrt �rtttct Permassaon is herehy granted to Construct( }Rep€ecr(xx)"Upgrade t :)Abandon( ) Sy tears lncated at 411 Si9m: 'l t Avg ` i�' z st4 ni Mori t a_. as dt.ss abed to the aboti a Appltcatwn for Drt pgsai SYster ti Consbpctton Permit The apRlacant ei ogmzes h he r duty to compty wttlde 5 and the fallotai locr{I pracxsrotu or special condrttgjas f f'xa1Rtdcd Cgm.,tm an rlaust be t amplcted wnhm three years of tha date al this n t N z g y L/.R ' : roar..' :MF Date " .,__�___�____ yr^ Apprlati e 3 t'y' > ` �� >r� E -�*--- ..:'.. ......w...... ...... ......:...... .:....... ............ ........:, ........:.. ............. NOTICE:This form is to be used for the repair of failed septic's stems on Y IY CERTIFICATION OF SKETCH AND A_PPL.ICAT[ON FOR A DISPOSAL WORKS CONSTIiIICTION PERMIT(WTTROUT DEsiGNED PLANS). L William E.Robiason Sr..hereby certify that the apphcatian for'disposal works _. construction permit signed by me dated 5-/g Z ,concerning the _. properly located at. 411 Scudder Ave,W.Hyannis ort.MA Jmeets all ... of the following criteria.. :::::::: _ I ere are no wetlands within 300 feet of the proposed septic,system ere are:,no private wells within 150 feet of,the proposed septic system Il The ohseved groundwater table is 14 feet or greater below the bottom of the leaching facility ere is no increase in flow and/or changc in use proposed. * There are no variances requested or needed. SIGNED:_ f/"- .:` 7 (Z �1 .L DATE::: J .. ..... LICENSED SEi2TIC SYSTEM INSTALLER IN TFIE TOWN OF BARNSTABLE NIJTVtBER 16 (Attach..a sket:c:h.plan;of the proposed;system...Also if the licensed installer proposes a certification .. .. . ... 01ot plan;this plan should be snlmutte _ •�+-1..,.__� st �. �4 � a as sail h r �-. f p er.• Msia�Mt..i.L..ateE�"'R Pua �� _F ��Q ll Rr >• # + • •IV11•Y son Oft . ,Ir aRn •'EL'M t ,!-r •,.en�C. Irl el LT i1ft YRR 1>1Y1U .s Tl�1 E �"IM�!"alrR ✓! �� T.a 1{ ,�. a '` "a.es s". A.Pi.03P ..15 PW► - -_'_._. i. rta # ns wEw4ir.f�!.m . ram•#R esY.imrvEr�to r.r,. K+ SJL.,7 ti9fp 7 '. CV4#L�ER arw+al rAr <af+aum • _ aYc ti }*fs1tPCvf1Tt 4CGiCNSS 'xC.. CALCULATIONS ON 0 f!lY•.yf t.yf'.. i $'�S',9.M iK2 Cfl{£ .a a halt i i k,Egt 60%0 A gyre .M! r a�rww� dam' i .►ra Raf H fNYYf N r i "RV t �%4r+..r nn ttif �; Lida.-) .iLitt� t1�a: • ILK 1101•Irk • •R3► Pb w gAal�(a�-r-lam .� R{r�Y aP Myr��t� - .: rfY I Raar w JarO ~i�yi�t W rt SHw Yie s -T MR - �M►fa Y•s M _,. fljK i4..M•n A� � w P! a. IR �.y�44 Nl ♦EI-.R/:; M. `. •1 t6 • Y �-.r.7 M4V Mire-^• s/�F•O•�sa�wl T w4 � -� Yam._-..e._ #l•reA rYr1YE wE c..R - T'R] YV+r,y f NOT& t RE�wr.a.1 YrE tY mr�Y 9 u• e - T r a eMIMIaya - 11��r Marl V I•.i�!�it a•fIw.f/LL - - c rr�r�R��R!�Iww YOO rAa m�R a/iE t1 OrR M• a as�r!a+r s iwl►n.r�.�.a.n ef ALL. I ftw=m mom y'`.• �{y. .a +�.r�r E arm Oi .f•rar wad•rE a ..i#•Y .arri f M M Ni:a Fey s�•..:.:..r¢�-fry t -a 1 gcRO��� 9JARi) OF EaeT1 R.�... *i � .. �� yX ir- fif.. � l.i♦ ,- FR �Lr.-K G_r`IL �. • PROPOSED SEP= DES _4.... 'j �aj' �,#Y♦ k ±�a f a.. Tf .. JRruL1[43 aJ1..:.0 iiaA '�.lC /! '^rf{701X•'(�cteaF a !` .;�rs�l -,•: aPt".'_! M R T - Z � Commonwealth of Massachusetts 6o44 1e �^ ,ip Title 5 Official Inspection Form f ;sc�?s44147 i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i "���/ � C � P✓ V t� , 4 Property Address Owner Owner's Nam information is required for every �A7 Q NVt0ovl page. City/Town State Zip Code Date of Inspe tion 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. �1�►t i�-t�of Important:When filling out forms A. Inspector I fo ation on the computer, use only the tab a key to move your Name of Inspector cursor-do not .LL�,JIV/1v/ O use the return Company Name key. I , " �QV� /C4-Y Company Address 44ea5 � If 0 �q), City/To V Q / (� State 1�4® 902 Zip Code tanan / / Teleph umber 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 15.000); 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 maintena of on-site sewage disposal systems.After conducting this inspection I have determined that the s m: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector 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. I 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. t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage(Disposal System-Page 1 of 18 P P 9 9 Commonwealth of Massachusetts Title 5 Official Inspection Form iii- Subsurface Sewage Disposal System Form -Not toir Voluntary Assessments � r `ill SC 4.4 .9' Property Address Owner Owner's Name f_ / I M information is W�,S T /� � 9' �d required for every VV � ',�' page. City/Town State Zip Code Date of In pectin C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) ;71 Passes: 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: 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. El 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fo Voluntary Assessments SC u Property Address Owner Owner's Nam S4 information is required for every &4 n r L—�� ✓� S page. City/Town State Zip Code Date of Insp ction 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): ❑ 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): 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 Property Address 1 Owner Owner's Name a information is / 1 0) 9 a� required for every page. City/Town State Zip Code Date of Ins ection C. Inspection Summary (cost.) ❑ 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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lf Property Address / �' Owner Owner's Nam `_'JL information is ' /✓� / required for every $S G✓)�)l S�" / ®�ro t?--)— 4a4v page. City/Town C7911State Zip Code Date of Inspe tion 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. ❑ 0/" Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply. ❑ Imo_'/ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El Anyportion 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.] ❑ e 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 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 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - of or Voluntary Assessments SC u Property Address � /•�� Owner Owner's Name information is WeS a 4 f 9� opt- required for every page. City/Town State Zip Code Date of Ins ection 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 27' to"yes" or"no"for each of the following for all inspections: Yes ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 a Title 5 Official Inspection Form Ike Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -A Owner Owner's Name y� l , na information is f / / ',A oo4r ) 9 p� 8 p�required for every page. City/Town State Zip Code Date of I spection D. System Information 1. Residential Flow Conditions: J Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / P ion,0 � //n� S �u/fecs Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes to If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes Rr No Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes �0 Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? �Cj Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form iIb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Nam(/ information is 23 required for every page. City/Town State Zip Code Date of Insp tion 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: ,tom Source of information: Was system pumped as part of the inspection? ❑ Yes eNo If yes, volume pumped: gallons How was quantity pumped determined? f Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts (P Title 5 official Inspection Form }i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ave, Property Address I Owner Owner's Name information is T / O l ��l a 940 required for every T ✓) . ' d- page. Cityrrown State Zip Code Date of Inspect'on D. System Information (cont.) 4. Type of S em: Septic tank, distribution box, soil absorption system ftA o J CAO er v ❑ 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 com onents, date installed (i known) nd source of information: /V 96 &%& - g6- gc5 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;4__0 ❑ cast iron PVC ❑ other(explain): 0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +' Subsurface Sewage Disposal System orm -Not for Voluntary Assessments Property Address Owner Owner's Name�,le Sinformation is required for every � � V page. City/Town State Zip Code Date of Inspe tion D. System Information (cost.) 6. Septic Tank (locate on site plan): n/� Depth below grade: feet ✓` Maten 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: /`�/ to Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle — 3 Scum thickness A/V -C 9,v e7 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.): caw n4w t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Yj/ Scad,�w Property Address ; Owner Owner's NamU4ej information is � f � Dj,(�1 d`-required for every sa'b page. City/Town WState Zip Code Date of l4ectiorl D. System Information (cost.) 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.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Igo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ave, Property Address +/ Owner owners Nam AA 1information is l e4 L.Z"'required for every `� N _ w.1 page. City/Town C=A I State Zip Code Date of Ins ection 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 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.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +' �I Subsurface Sewage Disposal System Form Not for Voluntary Asse ssmentsSc.. Property Address , Owner Owner's NaNm ✓�information is �'� /4 4 A4V / required for every TT � V page. City/Town State Zip Code Date of In pection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No* Alarms in working order: es ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 6-0.0 d" (0 * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) locate on site Ian, excavation not required): )� P If SAS not located explain why: P Y CType: S C4414, i ❑ leaching pits number: -- ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — --- —— t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Nam information is (AleSl required for every 4 r11�1f� � ✓� �db/o" _ / � page. City/Town State Zip Code Date of Insp tion 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.): 9., 1___C4e' &4 /' JI 0144", `! clrGv/ C G / , I �✓{/t 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.): i t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �n P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 1 Owner Owner's Name - information is Nam-1 f �&40 J O�/ l required for every page. City/Town — State Zip Code Date of Inspectio 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 �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - of for Voluntary Assessments Property Address S4-1II Owner Owner's Name information is M /� A �� required for every @s Y1Jm / �'T page. CitylTown State Zip Code Date of Ins ection 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 o nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the build! . Check one of the boxes below: ❑ and-sketch in the area below drawing attached separately 01 � L t5insp.doc•rev.7/2 612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 4 ✓ TOWN OF BARNSTABLE OCATION 6CULMAEA SEWAGE# kULAGE14 AN/Y/S)Cb*T ASSESSOR'S MAP& LOT98�-/V INSTALLER'S NAME&PHONE NO.MIAY,jam, lPo 8/410 V •- 7 ;'J-9k 71 L SEPTIC TANK CAPACITY [� �"t-' d- AU AJ ID C d,# /f1Arp LEACHING FACILITY: (type), ! hC CIJ ,r-X (size) IM A el U NO.OF BEDROOMS . BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: U d Separation Distan Between the: _ Maximum Adjusted Groundwater Table and 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 f ility) Feet Furnished bydL�i�S�� r. c.goNT Vourc Jop If L s rG G ; o S �� Commonwealth of Massachusetts Ip Title 5 Official Inspection Form .iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 % Property Address Owner Owner's Name information is 1 required for every page. City/Town State Zip Code Date of Inspecilion D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: , feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked witPg4 cal Board of Health- explain:r KS `� G S-� A4u ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must descr ow you est blished the high ground wa er elevation �cj� A � 4. O 4/0c✓ bo %1^1 014 _*'-T..'I-KI 11-te,a-4:X 105!O ti e C ken ' `OC ate', ✓1 40 T Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form iIo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 1.1 Owner Owner's Name P information is �ST required for every 7 page. City/Town State Zip Code Date of Insp ction E. Report Completeness Checklist Complete applicable sections of this form inclusive of: A. pector Information: Complete all fields in this section. B. rtification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summ ry: 1, 2, 3, or 5 mpleted as appropriate 4 F ' re Criteria and 6 Checklist completed � ) (Checklist) P 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r s' 9u � F � Gc. £ f S �., m ��i ,� i�`�vP�>wd"r,� ,���^�,�r ,++��V{�y "Y�1"y 3a'�'' 3K n ^���aa'% F mr ^�` ta• � � ftr ;:. ��_ ;` �"�"�; �a �t �,� ����z i N�'"�S.� C°"4 �<f r �� �r v ��,�w; �r�a t fk�a'�ai�,ad �';' � r � ✓ y§ i � �p �°&"'fx :'��' .i � .ty L'�!'• � � k ?r�F � �i 3' '4 �ti � ��«. �r � 7 � /�� a hvi s$' zt� a.>s h END �'-hr .;; Fjt 3t` r �`< z aa� ; 7 X InAIM a� ,;N1w^z�f kf A D2b yy ^ h tlr ' z�" Fm is r , mro` r ' So ��.3 �d ( r TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date LI I Time: In Out Owner Tenant Address l 1 I Address �. Complia a Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4.Water Supply r [-I—[ [ 5. Hot Water Facilities Approved.. .. 1 6. Heating Facilities D — 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing on 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here FORM30 ci&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH SZAM>L.f— CITY/TOWN = W H a DEPARTMENT OC7 M/s k A S ADDRES Y66) GSM SVO� TELEPHONE Address q1/ CSC_UOI)IAL AyC�tiiS O cupant_`'.'i9�Gr Floor Apartment No. A�- No.of Occupants No.of Habitable Rooms__ No.Sleeping Rooms 2- No.dwelling or rooming units No.Stories. Name and address of owner_ 9 V/0_4. t./N i ,O 9- S 1 L L Z/j/ SC c oozn. Avf—, y` AniNf S t-1GZ�7 Remarks Reg. Vio. YARD Out Bld s.: Fences: / Garbage and Rubbish V/ Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑'B ❑ F ❑ M Doors,Windows: `// Roof Gutters, Drains: Walls: O O 9/oti Foundation: 12_> 4V fA3 7 Chimney: /T 14 -7%M C, BASEMENT Gen.Sanitation: 7. Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten._,Gas,Oil, Elect.: c s, Flues, e s,Safeties: Kitchen Facilities Sink /d Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 6 wAv,4A- Al 4 x 7 40002. Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) THIS INSP CTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES F PERJU INSPECTOR TITLE�C-7 Z � DATE S Z TIME j 3 U P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 41O.48O(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 41O.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 41O.503(A)and 410.5O3(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. LDS S(- 1 SENDER, COMPLETE THIS SECTION, COMPLETE THIS SECTION ON DELIVERY ■ Complete'items 1,2,and 3.Also complete Mature, item 4 if Restricted Delivery is desired.. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address rent from item`17 ❑Yes If YES,Sy� �p below: ❑No �qv � •D � �\ N7A ST\L1... �� P �,� JAIL 0 6 2007 3. Se Ice T pe a rtifi all ❑ fare all ❑R e c+ etum ecelpt for Merbharlise ❑Insu � 4` 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (r►and/er from.service kW 7006 0 810 0000 3524 7885 PS Form 3811,February 2004 Domestic Return Receipt 102595-02•M-1540 i UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees;Paid USPS Permit No.G-10 • Sender:Please print.your name, address, and ZIP+4In this box• � l I I f I I I I ( I I I r i Certified Mail#7006 0810 0000 3524 7885 Town of Barnstable �� . r Regulatory Services + BARNnABLE..+ - go MASS. �g. Thomas F. Geiler,Director O s639• 1 prFA WO Public Health Division , .. Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 3, 2007 David& Linda Still P.O. Box 323 West Hyannisport, MA 02672 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 411 Scudder Avenue, Hyannis was inspected on Dece ber 27, 2006 by Timothy O'Connell, Health Inspector for the Town of Ban stable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violation(s) of the State Sanitary Code were observed: 105 CMR 410.482—Smoke Detectors: Smoke Detector not working. 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements: Observed entrance into crawl space that was not properly secured. 105 CMR 410.503—Protective Railings and Walls: Observed deck that is more then 30 inches above ground that was not furnished with balusters placed in intervals of no more then six inches apart. QAOrder letterMousing violations\Rental ordinance\411 Scudder Avenue.doc You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by adding balusters to guard rail on deck; by adding bulkhead to crawl space entrance or secure in accordance with 410.500; by fixing or replacing smoke detector. *Note: Hyannis Fire Department has been notified that there was an inoperable smoke detector in home that also did not have a photo-electric sensor in place. Also that there were no CO detectors in home. Hyannis Fire Department may be in contact if found in violation. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH h'ornas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Marcy Cote, Tenant Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\411 Scudder Avenue.doc Certified Mail#0000 0000 0000 0000 0000 Town of Barnstable Regulatory Services Thomas F. Geiler, Director Af� `"` Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 �fi date ?6 %`Q 3.1-3 na iVe address city,state,zip—�— NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE/ CHAPTER 170. 1 The property owned by you located at -T 1 I " was inspected (Address) on lam-/1�/ 1006 by ec , Health Inspector for the Town (date) (Inspect is n of Barnstable, ,,ti 2 (Reason for inspection) The following violation(s) of the State Sanitary Code were observed: State code violation number- iolation d scri tion 105.CMR 410. 50 3 Q 105 CMR 410. 6c O q WI(ILA' �e 105 CMR 410.ff - 7.�� b Q:\Order letters\Housing violations\Rentai ordinance\template.doc 105 CMR 410. The following violation(s) of the Town of Barnstable Code were observed: (Town code violation number-violation description) §170-_ - §170-_- You are directed to correct the violations listed above within 36) ( � ) days. _ (written (#� of your receipt of this notice by CIA- OIL- TO F' You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an,order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: (Name,tenant,owner,Fire Dept.,Bui d ng Dept....) Cc: - To (Health inspector's name) (Generic codes located at Q:\Order letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC) Q:\Order letters\Housin violation \Ft g s ental ordinance\template.doc HORessWARREN1m THE COMMONWEALTH OF MASSACHUSETTS FORM 30 �1 W BOARD OF HEALTH ' — �;►�►� �-ems CIT�Yp/TTOWWNN� a DEPARTMENT Mom•., Id-w�„�.�,,;::J n A- oa�o 'c`'+a say0 ADDRESS L O TELEPHONE [ _ .Address --_ —_---_--_--Occupant r Floor _Nff- Apartment No._�/_A-_—__ No.of Occupants__ No.of Habitable Rooms— No.Sleeping Rooms_____. No.dwelling or rooming units_N 1� _-___ No toriei--� Name and address of owner f,�,^ ,�- �3 IN�'�` /� Remarks Reg. Vio. YARD Out Bld s.: Fences: 6167.) Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: 0 50 Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: ©_ Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin : Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair Cy all TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den —Living Room i Bedroom(1). Fi,Va- o x Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: f Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE 99THE AUTHORIZED INSPECTOR.(See Over) \\`` "THIS INSPECTION REPOR GNED AND CERTIFIED UNDER TH PAINS AND PENALTIES OF PE JURY." INSPECTOR TITLE A.M. DATE TIME _ A.M. THE NEXT SCHEDULED REINSPECTION P.M. �.-. . .. , !' L.: ._ 7 `+:,.• ..-�'-.2-`_2"TM., l'�"4fi' „i+.sv.•� �, .� ,- -,;r?.wt FSk•' ♦ �:..�..-'b`-A''", .�. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. L Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. t J XN 7 N � Y r� AC1 re, ()Ufa r Parcel Detail Page 1 of 3 a, OV„ter 'MS' �0.CSASL. 211 fig Ov,N I it Logged in As: Parcel Detail Monday, °ctob, Parcel Lookup Parcel Info Parcel ID j28 137 � DeveloLooY OT 1 Location 1411 SCUDDER AVENUE Pri Frontage 100 .......... Sec Road Sec Frontage Village jHYANNIS Fire District HYANNIS _ Sewer Acct I {~ T� l Road Index[1440 Iu x„ Interactive Map Owner Info owner iSTILL, DAVID B & LINDA C �� Co-owner Streetl PO BOX 323 Street2 City W HYANNISPORT l State MA zip 02672- Country;US - Land Info Acres 0.39 _ Use Multi Hses MDL-01 l zoning FRF1 Nghbd 0111 Topography:!Level Road Paved _ P ........ .... .................. Utilities Public Water Gas,Se tic l Location Rear Location Construction Info Building 1 of 2 Year 1900��._..w_w__.____ l RoofGable/Hi �_..__ ._ Ext Wood Shln le Built Struct 1 p l wall[- _____�._g l Effect _.._.__ Roof _.�_ AC - Area IG095 Cover�Asph/F GIs/Cmp Type None _ l Style Conventional Int Plastered _ Bed 3 Bedrooms ....__.., ,..�,,..____,....._....1 Wall# l Rooms ._..._..M.._ Bath Model Residential m_ l Floor!— __l R oms i ' Full + 1 HI Grade Custom Heat 1 Hot Water Total 56 Rooms l Type, Rooms http://issql/intranet/propdata/ParcelDetail.aspx?ID=21885 10/16/2006 r Parcel Detail Page 2 of 3 Heat Found- E� stories Stories I Fuel F` as®�� ation Brick Walls Building 2 of 2 Year -920 I Roof Gable/Hip Ext Wood Shingle Built Struct Wall Effect Roof� __ AC Area �730 I Cover lAsph/F GIs/Cmp Type None Style,Ranch wall�rywall Roomds 12 Bedrooms I Model Residential Int Batn 1 Full I Floor w...__ Rooms p A Grade Average Minus Type Hot Air 1 Rooms�4 Rooms nK� �. Stories 1 Story Heat(Gas LiFound- Typical Fuel ( ation l� Permit History Issue Date Purpose Permit# Amount Insp Date Comments 1- Visit History Date Who Purpose 2/8/2002 12:00:00 AM Paul Talbot Meas/Listed 1/15/1988 12:00:00 AM ML i_- Sales History Line Sale Date Owner Book/Page Sale P 1 STILL, DAVID B & LINDA C 12195/134 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcc 1 2006 $278,200 $2,600 $400 $305,000 2 2005 $245,900 $2,400 $400 $207,500 3 2004 $202,800 $2,400 $500 $207,500 4 2003 $175,800 $2,400 $500 $69,200 5 2002 $172,500 $2,400 $0 $69,200 http://issgl/intranct/propdata/ParcelDetail.aspx?ID=21885 10/16/2006 Town of Barnstable Regulatory Services Thomas F. Geiler,Director t639. �� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 December 27, 2006 Attn: Hyannis Fire Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 411Scudder Ave. Hyannis,Assessors Map-Parcel: (288-137): -Smoke detector not working and was located within 20' of a bathroom and\or kitchen and did not appear to be a photo-electric smoke detector. Also no CO detector in home. 3, ou-a,-c Timothy 'Connell-Health Inspector QAOrder letterMousing violations\Rental ordinanceUire Violations\FIRE TEMPLATE.doc Town of Barnstable Regulatory Services BARDWABM Thomas F. Geiler,Director ts. a 9. �` Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 December 27, 2006 Attn: Hyannis Fire Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 411 Scudder Ave. Hyannis,Assessors Map-Parcel: (288-137): -Smoke detector not working. No CO Detector. Timothy . 'Connell-Health Inspector QAOrder Ietters\Housing violations\Rental ordinanceUFire ViolationsTIRE TEMPLATE.doc TOWN OF BARNSTABLE LOCATION { �j �, 0�� ,= (1.,, A SEWAGE # VII.LAGE e /Z ASSESSOR'S MAP & LOT INSTALLER'S AME&PHONE NO. SEPTIC TANK CAPACITY S 6 C LEACHING FACILM: (type) NO.OF BEDROOMS 3 - `/ (size) BUILDER OR OWNER, /I PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility C Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) r/ Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) J i Feet Furnished by b r J � l ,. TOWN OF BARNSTABLE LOCATION L� l C' C e n - ,' 12 AL - SEWAGE # 2 `'ULAGE D a- I ASSESSOR'S MAP & LOT INSTALLER'S AME&PHONE NO. ��.� .c-S 6 7 7 -7 Z SEPTIC TANK CAPACITY. �-< 6 LEACHING FACILITY: (type) '47' (size) NO.OF BEDROOMS BUILDER OR OWNER Z PERMITDATE: ` S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �. .�` .,— J� � c" `\� _ �� t A � e �� ` _\ �� c" q, - - �-II No. `" Fee p 5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migoml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 411 Scudder Ave Owner's Name,Address and Tel.No. 7 7 5-5 7 2 2 W Hyannisport David Still PO Box 323 Ir—Assessor'sMap/Pazcel 9 W Hyannisport, MA 02672 Installer's Name,Address,and Tel.No. 7 7 5— 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089 Centerville NIA Type of Building: Dwelling No.of Bedrooms -1/4 Lot Size sq. ft. Garbage Grinder(no) 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 sand Nature of Repairs or Alterations(Answer when applicable) Install Tit 1 P 5 s p_p t-i r system consisting of 1500 coal tank, D-box, and 4 stonepacked H-20 infiltrators. 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 issued by,. i9oard of Health. Signed AUY ' Date Application Approved by c Date-vim Application Disapproved for the following reasons Permit No. �" Date Issued No. ` Fee $$50.00� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS li r 2pplication for MigosW *p!6tem Construction Vertu t Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 411 , Scudder Ave Owner's.Name,Address and Tel.No. 7 7 5—5 7 2 2 W Hyannisport David Still PO Box 323 Assessor's Map/Parcel ; W Hyannisport,, MA .0 2 6 7 2 oi?fit I(. Installer's Name,Address,and Tel.No. 7 7 5— 7 7 6 Designer's Name,Address and Tel.No. " Wm E Robinson Sr Septic Sry PO Box 1089 Centerville MA Type of Building: Dwelling No.of Bedrooms 314 Lot Size sq. ft. Garbage Grinder(no) 'f Other Type of Building No.of Persons Showers( ) Cafeteria( ) 4 Other Fixtures f 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. j- I Description of Soil sand I Ij Nature of Repairs or Alterations(Answer when applicable) Install Title 5 septic system consisting of 1500 gal tank, D-box, and 4 stonepicked H-2.0 infiltrators. Date last inspected: ,Agreement: The undersigned agrees to ensure the construction an&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.,,,beeq issued by is and of Health. / n i Signed YeU P ' Date J ")9I `0 / Application Approved by Date Application Disapproved for the following reasons k' s Permit No. '' Date Issued ————————————————-———————————————-———— THE COMMONWEALTH OF MASSACHUSETTS still BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CnTI that the On-siyte Sewage Disposal System Constructed ( ) Repaired ( x)UpgradedAbandoned( )by 1/ , .b. at 411 Scudder Ave., W Hyannisport has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated '""� �� Installer Wm E Robinsons Sr Spt Sry Designer The issuance of this permit shall.not be construed as a guarantee that the system wi ncf on as designed. Date F� �" 4:2 Inspector —— No. 7.r '�l a� Fee$5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Still Mioogal *pztem Conotruction permit Permission is hereby granted to Construct( )Repair(xX)Upgrade( )Abandon( ) System located at 411 Scudder Ave W Hyannisport 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 following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this 't. Date: Z �� Approved 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) I,William E. Robinson. Sr. ,hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 411 Scudder Ave, W. Ilyannisport, MA meets all of the following criteria: here are no wetlands within 300 feet of the proposed septic system. here are no private wells within 150 feet of the proposed septic system. VT The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. here is no increase in flow and/or change in use proposed. here are no variances requested or needed. . STGNED: � ,/� DATE `` 7 —, LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). CA � ) f ` I TOWN OF BARNSTABLE LOCATION S C. /3 Ak /� A K6 SEWAGE # /%y r ASSESSOR'S MAP & LOT9 S ,,�V 7 INSTALLER'S NAME&PHONE NO.11oti1 l�o i3i/1✓cfQ s >',fj J SEPTIC TANK CAPACITY _TI_���= d LEACHING FACILITY: (type) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: O � Separation Distanc Between the: Maximum Adjusted Groundwater Table and 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 f cility) Feet Furnished byd �ilf Sig d UF 0 2' e ASSESSORS MANo. P 3 pf RCELFO; �.�j Fee $40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS 2ppfication for Migaal *potem Congtructfon 30ermit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 411 Scudder Ave. , W.Hypt. , MA David Still Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Sr. Septic Servic Criag R. Short P.O. Box 1089 Centerville-, P.O. Box 781 , Dennis, MA 0263 Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder(nd 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) According to Craig Short Plan # 1 -797 . 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 issued by this Health. Signed Date Application Approved by Date �- Application Disapproved for the following reasons Permit No._��; Date Issued �'"" Fee $40.00 t � THE OF MASSACHUSETTS F PUBLIC HEALTH IVISION -TOWN"OF BARNSTABLES MASSACHUSETT9 01pprication (or Migooal *pgtem Construction Permit p Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 411 Scudder Ave. , W..Hypt. , MA Dav&d Still Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. } WM. E. Robinson Sr. Septic Servic Criag R. Short P.O. Box 1089 Centerville P.O. Box 781 , Dennis, MA , 02638 Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder(nd C-< 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 Description of Soil Band 4 Nature of Repairs or Alterations(Answer when applicable) 'r According to Craig . Short Plan # 1 -797. f Date last inspected: t 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�ironentalland not to place the system in operation until a Certifi-cate of Compliance has been issued by this B Signed Date Application Approved by Date ' 77 fApplication Disapproved for the following;reaso s • Permit No. Date Issued —————————————————-—————————————————.———— THE COMMONWEALTH OF MASSACHUSETTS David Still X BARNSTABLE, MASSACHUSETTS ' Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or.repaired/replaced( )q on by Installer Wm. E. Robinson Sr. , Septic Srv. at 4.11 Scudder Ave. , W. Hy t has been constructed in cco•dan e with the provisions of Title 5 and the for Disposal System Construcrmit No. •' ted S " � Date 9 s.�- Inspecto THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. —— ——————-—————————————————————— 1 No. 7 a Fee�$40.00 David Still THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miopogar *pgtem Construction Permit Permission is hereby granted to Wm. E. Robinson Sr. , Septic Srv. to construct( )repair(x )an On-site Sewage System located at No.# Street and as described in the above Application for Disposal System Construction Permit. _ NO. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must beeccompleted within three years of the date below. Date: r-"" b ^- Approved by // .' ' G'�✓ Board of Health s CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) i, Wm. E. Robinson, Sr. , hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 411 Scudder Ave,, w.xypt- , MA meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: -41 z� DATE: ?— er LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER �f [Attach a sketch plan of the proposed system. Also if t tensed installer posesses a certified plot plan, this plan should be submitted]. F', E CHMARK 4• SCHEDULE 40 PvC PIPE FOUNDATI'JN - _ 1.0 FT. MINIMUM MIN. PITCH 11/8" PER FT. _ -. CLEAN SAND SOIL TEST2• LAYER OF DATE OF SOIL TEST= 7�_ _ 10 FT. MINIMUM 2' PRESSURE PIPE \ \ 1;8• TO 1/2• SOIL TEST DONE BY Iz r (ASSUMED) I 150 PSI MINIMUM E�EV. _ • ____ EL /Oi /ytfi wASNED STONE VENT WITNESSED BY F L CONCRETE y -- y ` X E-- ��"' 7s OBSERVATION HOLE 1 ELEV. 97, 9 OBSERVATION HOLE 2 ELEV.- �00 COVERS � _ - - I z 1 CU. F7. OF PERCOLATION RATE MIN./INCH AT _� INCHES PERCOLATION RATE MIN./fNCH AT INCHES CONCRETE DEPTH HORIZ T TEXTURE COLOR MOTT. OTHER FDEPTH HORIZ TEXTURE COLOR MOTT. OTHER ANCHOR L OF1M Y 7. •S rR 4" CAST IRON PIPE 1 �p I j � (OR EQUAL) MINIMUM 6• MAX. ,0• PITCH 1/4• PER FT. LEVEL �. , t 11Q ' / 1 L p�M Y i 0 YR LOAM y /� YR j -1--1- - - ELEV. = 6' SUMP = /DO ..30 � - AJ0 0 ..__ . . . ELEV it/ - /na„fo ELEV. __ /" 6 SFiND � S<i.cJO 3�4 FLOW LINE �7- 10. .� _--_. ELEV. _ �- I DISTRIBUTION Env s T�vFi�Tae1�Tt�R.3 w z s r ,tea C RA w L -TMIN. 19- CoAR sue' /o Y/z a/o 3� C' s A ,va ----- -- - S �A C E T GAS a. 3/BOLDRILL ©0 X S TO �vE� !N F' Z c.'oAq,es e' z ,SY l ELEV. - G'�� BAFFLE N TO BE WATER TESTED 11 "� 34 x /O TRENCH FORMATION i WELLMiW 2 C, SAND S/B �- C ELEV. - s b SOIL ABSORPTION v� NDEX _Z- SAA. D "�` �� CHECK ADJUST � 20 VALVE 3/a• To , 1/2•- SYSTEM (SAS) 9G' o " Ow (TO BE PLACED ON FIRM BASE) WASHED WASHED STONE / 6 - 2 -= , E .. L3.�.� x 500 GALLON PUMP USES PROBABLE WATER TABLE ELEV. = a ` 4 WATER ENCOUNTERED AT Z / ELEV. r 22•8 WATER ENCOUNTERED AT 7• ! ELEV. 9 SEPTIC TANK CHAMBER UUi)LKVED WATER TABLE ( `//8/9L> ELEV. = ELEV. AT INVERT INLET _96-1.7 PUMP CHAMBER CALCULATIONS: LEGEND: DESIGN CALCULATIONS ELEV. AT ALARM ON i SO a sr ^ EXISTING SPOT ELEVATION 00,�0 NUMBER OF BEDROOMS E -53c' ��t.UJA(�E DISPOSAL SYSTEM PROFILE ELEV. AT PUMP ON 7 3 ; %�' REQUIRED F!-OW PER .25 X _ CAL./CYCIF // / EXISTING CONTOUR ----00---- GARBAGE DISPOSAL UNIT _b!d W� VOLUME PER CYCLE •- GAL/CYCLE /7.48 GAL/CU. FT. CU. FT. CYCLE NOT TO SCALE ELEV. AT PUMP OFF T"- FINAL SPOT ELEVATION TOTAL ESTIMATED FLOW BOTTOM OF INSIDE PUMP CHAMBERS VOLUME OF WATER IN PIPE 3.14 X 0.00694 X FT. _ CU. FT. FINAL CONTOUR _ ( = GAL. 'BR. ) �_ GAL./DAY TOTAL MINIMUM VOLUME PER CYCLE / /DAY X 3 BR. �� � w CU. FT. 90T fOM OF OUTSIDE PUMP CHAMBER _LL_'Zii �- SOIL TEST LOCATION f9 REQUIRED SEPTIC TANK CAPACITY )J C-2 GAL DISCHARGE Co. FT. / 34.67 CU.FT./FT. = • 32 FT. (1000 G.S.T.) UTILITY POLE --I? ACTUAL SIZE OF SEPTIC TANK GAL STORAGE CAPACITY ( J-430 GAL./DAY /7.48 GAL./CU.FT./34.67 CU.FT./FT. _ J FT. J � , � 7. � � � J� TOWN WATER �W-�=-•W-=-= SOIL CLASSIFICATION r t�QY �� � lie. . �,. CATCH BASIN DESIGN PERCOLATION RATE <,�_ MIN./IN. I GAS LINE -- - EFFLUENT LOADING RATE GAL./DAY/S.F. LEACHING AREA f*2/ '� SQ. FT. LEACHING CAPACITY (AREA X RATE) 33/ GAL./DAY \ A -4 - . "'4 RESERVE LFAUHING CAPACITY ^�/FI GAL/DAY N 0 TE S 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. LFL jE V." / O . 7f TITLE 5 AND THE TOWN OF RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO ` WITHIN 6" OF FINISHED GRADE. 2 ��„ �-�• t 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN \ _ 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE \\ TN2 USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALI BE MORTARED IN PLACE. 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER j APPLICANT IS TO I `y KU _ OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. �D' E 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR IS TO CALL 'DIG-SAFE' AT 1-800-322-4844 AT LEAST 72 HOURS C p �•. PRIOR TO COMMENCING WORK ON SITE. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS C3 o go4-j F 0 V / �,� SITE CONDITIONS PRIOR TO COI�ENCING WORK ON SITE. 0 \ C4 -,C P 8. PARCEL IS IN FLOOD ZONE -� "oe CK/ r ' ; % I 9. LOT IS SHOWN ON ASSESSORS MAP " AS PARCEL 1V 10. PUMP AND ALARM ARE TO BE ON SEPERATE CIRCUirS. 11. ALARM IS TO BE BOTH AUDIO AND VISUAL- All L 12. SEPTIC TANK AND PUMP CHAMBER ARE TO BE TESTED TO INSURE �yB• / Q d ^^� ^, THAT THERE IS NO INFILTRATION OF GROUNDWATER INTO FACILITIES. 13. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER AND FOR A MINIMUM OF 5' AROUND SOIL ABSORPTION SYSTEM AND BE REPLACED WITH MATERIAL AS SPECIFIED IN 310 CMR 15.255:(3). 7 / �O y� O t 14 ',;r �l -5 4- 1 A/E 7-do m6 r'V.R:-4 j dF.r: #,..",•. --� U % o C cs �v -r•- /0. 2. 4 C- On T APPROVED: BOARD OF HEALTH �� �• -� -v L FA G H T R E W C H (SA Si -- t9 DATE AGENT FIST• aOX - - �� io\ - r PROPOSED SEPTIC DESIGN � 9\ � � 5E � )V�JT � l � `- h, FOR i •• �A \\ , i / PUMP �..H.A l+. K i PROJECT LOCATION 1 411 SCUDDEf< AVE R If 7.4 ,,, N R.. w.y L L It I �, y�4 Al `S p0 rQ 7 �;ASS , i � J F Y ry C'Lt,, �.c� � T o P � ,Ea E V�i o O, 7S _c rzL3,� SM/1'h --- - _- --- ----- ----------------------- - -------- _ SS �o o �.,� 7 0 < ,a SLO Pg 7- P ro G.P-09Z E �� ' CRAIG R. SlIORT L ISO --,A 4� p�-V� � 'S' ra PROFESSIONAL E'IvINEER T F M C7 �s er1) 5Q8_ P. 0. BOX /81 -�rAN i,� �� /�/ 4 L 385-6530 D`NNIS, MASS. 02638 Ile _ ( SCALE 1 i DATE 7/3�/9� ----'V, �NOF V'v� L-- ------- - - J OF MqJ. __�- ------- - ---- -- - ---- - Wil V K r REVISED - REVISED _----- -� L o CRAIG y SHORT 4,/Y y g N --i- - --= -- -- l- ------ ---- o CIVILv-", - ----- - --- --- -- -- -- - -- - --- - -- --- --1 - ' No. 27483 r LOCATION MAP \�B NO. - _ r1tET 0� �o �F L�---- - -- - --- - �- - --- ------ - - - - ----- ----' 01995 CRA.(, P. SHORT, P.E__