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0639 SCUDDER AVENUE - Health
639 Scudder Avenue Hyannis A= 287 - 049 a � 1 i Y� u ri S M E A D No. 2-153CR UPC 17734 amead.com - Made in USA l i 1 j I v \�\ � i I a TOWN OF BARNSTABLE �d LOC/Ci TON -6:341 &--QCWeril'C SEWAGE# VILLA ASSESSOR'S MAP&PARCEL X7-D� /- INSTALLERS NAME& HONE NO. &-WO` ( t SEPTIC TANK CAPACITY IS-®© �.,-�e 1 Oi'I -,Zp DtJ-'P1As( � cuer��►„���p LEACHING FACILITY: (type) �" (size) NO. OF BEDROOMS 6> OWNER C-a- DaX"f� j PERMIT DATE: l��a6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within300 feet of leaching facility) Feet FURNISHED BY i 3dbp- d � � o a V TOWN OF BARNSTABLE LOCA`t�iON �v JGU`GG/ AVt. SEWAGE # VILLAGE ��' P 0 ASSESSOR'S MAP & LOTDVZ0419 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Slit fC CQ:SJ 001; LEACHING FACILITY: (type) (size) NO. OF BEDROOMS b CJp�� 1 BUILDER OR OWNER �� ;q G-,SO lilt PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching f ccility) Feet Furnished by Lr1SPC L"t t0✓t T Fpl/ � I P F D 1-- j r o I 7F N o C No.. �'� a� Fee ko THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for �h6po!6ar 4pgtem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade 0< Abandon( .) l_Complete System ❑Individual Components Location Address or Lot No. (©39 ,5cu w5k "I Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Install s Name,Address,and Tel.No. Desi ner's Name,Address and Tel.No. 06 a-"'mvpWl C 0`v 5ri I NJL, U W Q Crt.Q &A3Ca-t va£-ir tbr Type of Building: Dwelling No.of Bedrooms Lot Size 7r sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) + fs gpd Design flow provided („ 7 gpd Plan Date d ZL %S Number of sheets / Revision Date N 1,4 Title p Size of Septic Tank CSO0 oA _Ja Type of S.A.S.-Mn C.M (e-506 CV4414" Description of Soil S S (fY LA-,� 10`T3 f F"V_� Nature of Repairs or Alterations(Answer when applicable) (N-S T7>LA- i4- (�5SQ 4EjL4 j V-n L 7 YMl U-- 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 E onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of alt . Sig a Date Application Approved by 0 Date Application Disapproved I Date for the following reasons Permit No. Date Issued No. (/t� ..../ aw r=*r. ' — Fee t " t �, computer:Entered d in com TH:E COMMONWEALTH.OF MASSACHUSETTS p YesI .# J .1 � if ..PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppYication for �i.5poal ,p 'tem Con5tructioit Permit Application for a Permit to Construct O Repair( ) Upgrade(X Abandon O E Complete System"' Individual Components �t Location Address or Lot No. cj cu DJ� /W Owner's Name,Address,and Tel.No. \\\ Assessor's Map/parcel 7 , Installer's Name,Address,and Tel.No, 1�4 Desi ner's Name,Address and Tel.No. a Q�"O Wes} 4 rJ S i^ a w•J C�4 i✓�G—�uv,LV-I N 1 r I�t C .� zr►s�'�'I R..� ,M ,.v1��45 ��Y�3'- �9 /'3► !�-�G A- y�.u,,�t f�rtr 5Z1�=3(�-`ts�/ Type of Building: _Dwelling No.of Bedrooms Lot Size s vr7 y -�sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) F ` Other Fixtures ` • r Design Flow(min.required) gpd Design flow provided 6, 67 gpd V Plan,,. Date d 1 S aCsS Number of sheets Revision Date �. J.A Title Size of Septic Tank S60 cvA A Type of S.A.S. 7/0, ��a� WDescription of Soil c 15s '��1-ti1 �3' Nature of Repairs or Alterations(Answer when applicable) (NS T-A" A- (z 110At4. d-TI L / 14-, d) l�S�i= 4&G L, (/6 Y-1 x 3-7—V� � � Z/1"_M t,/,1 jd 0 S t n1 r:. (11 Date last inspected: ' Agreement: ; t r- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ' accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of `s Compliance has been issued by this Board of Hedlt . Signe / Date 9 Applicatiori`Approved by � _ Date > Application Disapproved by: t v f�. / / / Date " for the following reasons Permit No. /i Date Issued �.y.. T THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) y,-Abandoned( )by YS p A:;�0 W WN GQ NJ )/I+V(r1 01J at ' f!� 3q W b6 V,_ 14*' G"j'VF f JJ I 01C, _ has been cojistructed in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. , dated vi- Installer Designer #bedrooms (o �. _ Approved design flow �0 � 60 LQr'1 gpd The issuance of this permits all not be construed as a guarantee that the system wi functi,n as design d. Date Clv� �210V Inspector t < � ---No. � ---0/�-� '. —... —__—------------------ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH-DIVISION—BARNSTABLE, MASSACHUSETTS =i!5pogar;*pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (0<Q. Abandon ( ) - System located at G 3 9 R 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 cond' Provided: Construction must be completed within three years of the da e of this e t. Date f 3/� Approved by Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name / information is required for every y p West H annis ort V MA 02647 5/24/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. .mu. Important:When A. General Information 61. c L� _ " - `- -.Y= filling out forms l�/ r �33 / on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services, LLC tab Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number .License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further valuation by the Local Approving Authority -\WOU 5/26/17 Insp tor's Signature Date The stem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is West Hyannis port MA 02647 5/24/2017 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 page. CltylTown 5/24/2017 State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >•''y 639 Scudder Ave. Property Address Mark Freitas Owner owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a,•'•y 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 1.5,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 page. City/Town 5/24/2017 State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M A 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped in 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 9/22/06 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: 1500- H-20 Sludge depth: 1 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. There was no sign of leakage The inlet cover was 6" below Grease Trap (locate on site plan): Depth below grade: n/a 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 �, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5a Inspec7 page. Cltyrrown State Zip-Code Date of nspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm,level: Alarm in working order: ❑ Yes ❑ No v Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 of Inspection page. City/Town State Zip Code. Date of nspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 lit Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 City/Town —bate 017 page. State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 -500 gal. chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The chambers were dry and clean. There was no sign of failure A camera was used 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 I Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 page. City/Town State Zip Code Date date 017 of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately (jA rAbt_ t 0 a 0 3 d Lol a0 ay 3 aY` 30 y aq y Y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 9 639 Scud der Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 page. City/Town State Zip-Code Date date o2017 of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25'+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Topo and water contours map. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 Scudder Ave. Property Address Mark Freitas Owner Owner's Name information is required for every West Hyannisport MA 02647 5/24/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 l Bk 25908 Ps 4O -gar-62535 12-09-2011 a 12= 44p RESTRICTION WHEREAS,Mark L.Freitas of 201 El Vedado Road, Palm Beach, , Florida 33480 is the owner of certain real estate situated at 639 Scudder Avenue in the Town of Barnstable known as Hyannisport, County of Barnstable, Commonwealth of Massachusetts 02647,hereinafter referred to as"the Premises",and more particularly bounded and described on the EXHIBIT A attached hereto; and. WHEREAS, Mark L. Freitas as owner of the Premises has agreed with the Town of Barnstable as a precondition to the granting of a building permit for renovation and additions to the existing structures now located on the Premises to restrict the total number of bedrooms which can be included on any buildings located on the Premises. NOW,THEREFOR, Mark L.Freitas does hereby place the following Restriction on the Premises above referred to in accordance with his agreement with the Town of Barnstable Building Commissioner, which Restriction shall run with the land and be binding upon all successors in title. (1) The buildings as renovated on the Premises shall have a total of no more than six (6) bedrooms. (2) This restriction shall continue in full force and effect until such time as the Premises shall connect to Town sewer or the premises can have more than six(6) bedrooms as allowed as a matter of right,at which time,the Restriction shall become null and void. For title,see deed of David G.Anderson et als,Trustees of Doris T.Anderson Declaration of Trust dated August 23, 2005 and recorded with Barnstable County Registry of Deeds in Book 20233,Page 240. Witness my hand and seal this day ofWARF L)pQ AA'' L.F ITAS STATE N OF &J U - COUNTY OF On this '�'� day of 2-61 Y\ , before me, the undersigned notary public, personally appeared, Mark L. Freitas, >roved to me through satisfactory evidence of identification, which / or- to be the person(s)whose name(s) is/are signed on the preceding or attached document,and acknowledged to me that he signed it voluntarily for its stated urp . i i f 1. ��, Notary Public My Commission Expires: �o (Affix Seal) Re"J.Thue* Nolan/Pubes-Stale of New York Coed In Wngs County N%01TH6241089 Commissfon Expires May 18,2015 .s Bk 25908 Pg 41 #62535 EXHIBIT A A certain parcel of land together with buildings and any improvements thereon, situated at 639 Scudder Avenue in the Town of Barnstable known as Hyannisport, County of Barnstable, Commonwealth of Massachusetts 02647,more particularly bounded and described as: Beginning at the southeast corner of the premises at an iron pipe at land now or formerly of Anna Ould;thence running North 7 degrees East, 110 feet b land now or formerly of Clinton Sturgess and Evelyn W. Y Y g Y Hallett to an iron o pipe and land now or formerly of Edith P.Treat;thence running North 87 degrees 45' West, by land now or formerly of said Edith P. Treat, 212 feet to Scudder Avenue;thence running South 0 degrees 30' East by said Scudder Avenue, 120.10 feet to land now or formerly of said Anna Ould;thence running North 89 degrees 15 East 197.40 feet by land now or formerly of said Ould to an iron pipe and the point of .be innin g g Also a certain parcel of land adjoining the above-described parcel on the Northeast corner being bounded and described as follows: Beginning at the northwest corner of the premises at an iron pipe and at the northeast corner of the above-described parcel;thence running North 83 degrees West, 80 feet by land now or formerly of Edith P. Treat to an iron pipe and LaFayette Avenue;thence running South 7 degrees 0' West,by said LaFayette Avenue ten(10)feet to an iron pipe and land now or formerly of Clinton Sturgess;thence running South 83 degrees 0' East by land now or formerly of said Clinton Sturgess, 80 feet to a point in the easterly line of the first described parcel;thence running North 7 degrees 0' East,ten(10)feet to land now or formerly of said Edith.P.Treat and point of beginning. Said premises are subject to a right of way described in grant from William France Anderson et ux to Godfrey MacDonald recorded with said Deeds in Book 707,Page 125. Said premises are subject to and have the benefit of rights of way,easements, restrictions,rights, reservations and agreements of record insofar as the same are now in force and applicable. BARNSTABLE COUNTY REGISTRY OF DEEDS A TRUE COPY,ATTEST DAii�STADkE REGISTRY OF DEEDS JOHN F.MEADE,REGISTER FROM :down cape engineering inc FAX NO. :15083629880 Sep. 25 2006 08:35RM P1 Town of Barnstable Regulatory Services Thomas F. Geiler,Director XAM 3 sus Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 509-962-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# 106 'D 05- Assessor's Map\Parcel��F� Designer: �� �^ Installer: o G� Address: cu3 t"",, st— (}� Address: 1 On q was issued a permit to install a (date) (installer) septic system at L 3 5�. �,+ AV,.— based on a design drawn by (address) dated l �- I S' o5 10, (design ) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such. as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan.revision, or certified as-built by designer to follow. 1H OF MASS ARNE H. o,� (Installer's Signature) OJALA CIVIL. in No. 30792 S� �N (Designers Signature) (Affx DeUVWWSlarnp Here) PLEASE RETURN TO BARNSTARLE PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL. NOT BE ISSUED UNTII, BOTH THIS FQRM AND AS-BIwJILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. i Q:IicaWSeptic/Designer Certification Form 3.26-04.doe New Page 1 TORN OF BARNSTABLE LOCATION _ �[ �� �.!'e SEWAGE#��S E Gdr f AAssESSORLS MAP&PARCEL X7-OVIILAGEMB c R� ''INSTALLRNA SEPTICTANKCAPACITY 15-00 /'.,,m(63 LEACHING FACILITY:(type) �� _ (size) a2Q .I NO.OF BEDROOMS OWNER E•aT. 3a*X PERMIT DATE: AI l 66 COMPLIANCE DATE: o� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) Fed FURNISHED BY Rob lie r to!o ili { -+ f• A q 7- As- 6 ram-9 ' Crj (? o ° G s=38 W P 9/6/2010 2:34 PM 1 of 1 luo 008 r r SENDER: COMPLETE�VHI=EGIM —(AWAALE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. , El Agent ■ Print your name and address on the reverse X LYZ i4C41 ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Datp 91 Deliv ry ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? es 1. Article Addressed to: If YES,enter delivery address below: ❑ No Ms Barbara Andereason � 184 East Bay Road. Osterville, .MA 02655` 3. Service Type ❑Certified Mail ❑ Express Mail ❑Registered ❑Return Receipt for Merchandise •❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (fraTfer from sgrvice label) PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 all UNITED STATES POSTAL`"J RVI First-Class Mail Postage&Fees Paid I USPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I I PUBLIC HEALTH DIVISION I TOWN OF BARNSTABLE 200 MAIN STREET I HYANNIS, MASSACHU SI FTS 02601 I i ly. �' g 4s 7 M p Postage $ OH S WA Q Er Ln Certified FeeCO a ,1� + Return Receipt Fee XM (Endorsement Required)qRestricted Delivery Fee O (Endorsement Required) O p Total Postage&Fees ' use C� ,n Sent To S -----------r S a -------------------------nee---s-- _ Street,Apt.No.;or PO Box No. Cast -s_�__._ M Ca ivr -------5----------- p C State,ZIP+4 TT r Certified Mail Provides: M A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For ` valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece `Return Receipt Requested".To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 af-- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 639 Scudder Avenue Hyannis Port, MA 02647 Owner's Name: Doris Anderson S Owner's Address: 229 East Lake Shore Dr.,Apt. 5 Chicago IL 60611 ^; , Date of Inspection: July 13 2005 ? =' 0 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 0 Osterville.MA 02655-0049 = Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage.disposal system at this address and that the inf rmation reported' below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fai Inspector's Signature: Date: July 20, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.' Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I • Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have detennined 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. NOTE:SINGLE CESSPOOLS A UTOMATICALLY FAIL IN THE TOWN OF BARNSTABLE. E. Large System: ' To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 t Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n1a Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n1a Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system 10) 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Date of installation unknown-House built in 1763 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: None (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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes of no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 SOIL ABSORPTION SYSTEM(SAS): None (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation;etc.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) #1 -Garage w/1 Bedroom 92-Main House 43-Off Main House Number and configuration: I single(steel cover to grade) 1 single 1 single Depth-top of liquid to inlet invert: -- -- 2' Depth of solids layer: 0" -- 0" Depth of scum layer: 0" 10" 0" Dimensions of cesspool: 5'W x 6'T x 8'bottom to grade 5'x 5'x 7' 5'x 3'x 5' Materials of construction: Block Block Block Indication of groundwater inflow(yes or no): No No No Commnents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool 42 was dew in heavy brush. A video camera was used for the inspection. NOTE:Single cesspools automatically fail in the Town of Barnstable. PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. -------------------------------------- G A � - (3q�k ' 1 1-7 S8 a s� to i Overg ro W f3ru sh , 1 � 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 639 Scudder Avenue Hyannis Port, MA Owner: Doris Anderson Date of Inspection: July 13, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topo,raphic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Usin-z Barnstable topographic and water contours maps, the maps were showing approximately 30'+/-to Around water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. 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'J^ - -- ------------------- - - - �f �- RiT n'oE Zy� "�ci'ri o c yxp o (1 n Y O r a'Z "� °fin z wye.n,op xK n ii ' �� Yoo m� a rn 3 6 e, In �x on +5 xd, o � a z — aYzr.40 a TIC, ���om s Aoa - o IIIT s.m aNN ?, CO E`J�i1NG r y O� S F /C C�� r m N n 1 p a� o 0 !� S113SnNGd C 0 z a m on Q Sunroom Addition to the Achi-Tech Associates.Inc.he,eby g SWY rase es the copy,ight of __ .. m .. th se drawinps accerdin to the _ _ Freitas Residence A,hilecluralvWerks Copyright Protection Act'of 1990.Anyy ppy, G aIT n D Iteration,rap,.d.clic.or Eis bibu- ���� ZlL, �j `:y irr P 639 Scudder Avenue lion el these plans,ilhout the 6 school street Q 508.420.5335 ii 508.420.5304 x 'm u .press wlitlen consent of Arch! `� Fj o a H annis ort, Massachusetts express ate+.lnc.•iaaai.onnes- II�11 ) / � • cotuit, ma 02635 Q info@architechassociates.com I of Ihal act.Any err n I 3 o ons or diacreppancIas on Ihese I�JI m drawings shall Le broug hl la the Foundation & First Floor Plan on of Archi-Te h Aaaoo- �ncaPrio,to toginning d,do net architectural design architech associates.com. ensiona are to be used,do not - sale dnwinga ------------ SEPTIC PROFILE NOTES - FIRST FLOOR 47.0' (USE H-20 -COMPONENTS) COVER TO FIN. GRADE . ASSUMED LEGEND SEPTIC DESIGN: 7 ACCESS (NOT TO SCALE) PROVIDE ACCESS PORT TO 1. DATUM IS GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVER (WATERTIGHT) TO FINISH GRADE 100.0 PROPOSED SPOT ELEVATION /4-2.07' MINIMUM .75' OF COVER OVER PRECAST /r FIN. GRADE 2. MUNICIPAL WATER IS AVAILABLE 2% SLOPE REQUIRED OVER SYSTEM 110 GPD) 660 GPD DESIGN FLOW: , 6 BEDROOMS PER FOOT. 10OXO EXISTING SPOT ELEVATION 2* DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8 VANCHESTER USE A 660 GPD DESIGN FLOW RUN PIPE LEVEL �42.0' -FOR FIRST 2' F1 6� -0 PROPOSED CONTOUR SEPTIC TANK: 6§0 GPD (2 1320 PROPOSED 1500 3' MAX. 0 - (PROP) 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-20 LEA LOWS USE A 15TO GALLON SEPTIC' TANK GALLON SEPTIC 3-9-_00 TEE H-20 CHAMBERS 100 - EXISTING CONTOUR 39.25' TANK (H_ GAS Ipw N 37.0, 5. PIPE JOINTS TO BE MADE WATERTIGHT. LEACHING: 36.39' NVFT 3 .56' 01 03 r-1 0 M 0 17-1 1:3 2(58 + 10,63) 2 (.74) 203 Fk;1_ H-20 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. SIDES: MIN R95911 QRS 36.17'/ ED r_1 [z] 0 ED 17-1 0 71 0 58 x 10.83 (.74) 464 (__�LX SLOPE) �_6* CRUSHED STONE OR MECHANICAL 0 171 M 0 171 E:1 171 1--] M ENVIRONMENTAL CODE TITLE V. WACHUSIM BOTTOM: - I - -1 0 1:3 171 1--] 03 COMPACTION. (15.221 (2]) 2 0 171 13 r 34.17' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE TOTAL: 902 S.F. 667 GPD DEPTH OF FLOW 4' (-!8x SLOPE) (-!-X SLOPE) i USE (6) 500 GAL. LEACHING CHAMBERS (ACME OR TEE SIZES: 3/4- TO 1 1/2- DOUBLE WASHED STONE USED FOR LOT LINE STAKING. IRMNG AT ENDS INLET DEPTH 1( " EQUAL) WITH V STONE AT SIDES,A4D 3.5 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 14n OUTLET DEPTH LOCUS MAP 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT HOUSE FOUNDATION 15' SEPTIC TANK 13' D' BOX 24' LEACHING 6.67' INSPEC11ON BY BOARD OF HEALTH AND PERMISSION OBTAINED NOT TO SCALE (MAX) FACILITY FROM BOARD OF HEALTH. FROM GARAGE 48' ASSESSORS MAP 287 PARCEL 49 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE MA LOCATION OF ALL UNDERGROUND '& OVERHEAD UTILITIES PRIOR 'BOARD OF HEALTH TO COMMENCEMENT OF WORK, APPROVED DATE BOTTOM TH 2 EL. 27.5' TEST HOLE LOGS A. H. OJALA, PE ENGINEER: DON DESMARAIS, RS b WITNESS: +39.40 DATE: 12/12/05 PERC. RATE < 2 MIN/INCH I SOILS p# 11180 CLASS +39.00 ELEV. ELEV. on 40.5' 0" 38.5' A A LS LS PROPOSED RE-ROUTED PLUMBING list 10YR 4/2 1 OYR 4/2 12" EXIT LINES TO BE CONNECTED INTERIORLY TO EXIT IN AREA t4l.82 j B SHOWN B +46.76 (CONFIRM FEASIBILITY WITH LS I LS PLUMBER PRIOR TO INSTALLING +46.57 ANY PORTION OF SYSTEM). 1 OYR 6/6 1 OYR 6/6 +4 66 30" 9�4 -4 30" GAS ----------\41.56 -+3147a C11 §313 C1 �-42.6 212.00' 4b.4/ 94 1 -+-37.96 80.00' SL SL LOT AREA 44. -�Oly 24,274 ±SF 45 GRAVEL LI ',p;r DRIVE ------------ -02 -1 OYR 6/4 6. \41 1 OYR LAWN--,-., 6/4 OH VWRES 45. 3\4 8000'5�1-- 4 5.2 4 +4 40 ;C9 6 -�_40_00 48 36.5" 48 E 49.84 134.5' �-+5442 6.3� I OH 4�7.54 C2 2 C;ASURE C2 6 4 lb INV OUT PERC LS PEIRC 46.28 EL=44.16' IN OUT EL=44.43 �5 LS EXIST. i6. 7 GARAGE 1 OYR 6/3 .75 45.61 EXISTING O� )0 ,J.91 120" 30.5' 132" 1 OYR 6/3 27.5' ► DWELLING 0 5.58 .04 73 b EMOVAL OF UNSUITABLE SOIL REQUIRED 5 R NO GROUNDWATER ENCOUNTERED Q'i446.02 30* MAPLE AROUND PERIMETER OF LEACHING FACILITY, 41.1,3 DOWN TO SUITABLE SOIL LAYER. REPLACE +4a.95 /3 3.85 0 z -45,2 4., an__ WITH CLEAN MED. SAND. LLI 4 .22 0. 3 45.60 GARAGE W/ RL < WATERLINE < I �77!� CL ------ - A,�L.5 9 +44.63 ROOMS 39 45 U-t --+45.51 4 4.5, ABOVE 1 01 0 1 / I I I SLAB 1 0 Ld i I EL=41.5' _44��,�,.14 40 0. 1 9XI LLJ EL.-40.55' INV OUT 10* MAPLE +4L 4 PROP. VENT WITH CHARCOAL FILTER ._ / t43-1582-99 AND BUGSCREEN .. .FINAL PLACEMENT BY +-44-.94 LAWN CONTRACTOR WITH HOMEOWNER LAWN CONSULTATION) I CP I - TH2 �+,4 4.7 1 _q�,37 7.7.? TLE 5 SITE PLAN 2+- MAPLE +44.52 -�42.76 OF X BENCHMARK: USE GARAGE 4442.92 1/ 1 SLAB AT ELEVA11ON 41.5' -44.23 34,78 -+14.06 w wa f-7- 639 SCUDDER A�,/ENUE 197.40 1-lYANNISPORT PREPARED FOR �44.65 IL A BORTOLOTTI CONST./JAXTIIVIER DATE: DEC. 15, 2005 Scale:1 20' 0 10 20 30 40 50 FEET off 508-362-4541 fax 508-362-9880 down cape en eering, inc. �A 0 1 M.,I _4A SS �A OF E CIVIL ENGINEERS ARNE 0 LA JA LAND SURVEYORS CIVIL, 48 2co No 30792 939 main st. yarmouthport, ma 02675 cnu DATE P.E., r4 ALEN 05-291 XXXXX.DWG 39.25/ E 31 -------------- 36.5�MECHANICAL �36.39' ED 0 ICALA 24 ---- ------- 4 .22 ,1.60 --4-44 0, A E R H 0 LA i 6 is Orn a Spence 14961592 l ' , " t ?a ada _.. Ei I" , ' V� '0 ' �. 00 , 00 .�". `— �Pa C . C � , 00 S / rf a ° " � -- Owelflng ................... .. ' : ............................ ., . CL W ffn c/o Porch � r ..... ..................._ NI .................. . 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