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HomeMy WebLinkAbout0116 SEABROOK ROAD - Health 116 Seabrodk Lane 07 18 307-018 Hyannis l i J ,i i No. / I j Fee 4`—,5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPYitation for 30isposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X ❑Complete System ❑Individual Components Location Address or Lot No.11(p :5C_A3W L OA Owner's Name,Address,and Tel.No. �Ar\MS Mr4�"NO �NuA Assessor's Map/Parcel ,gyp 6(g 4'5ijxj5e7' LA J e LU4E)J'00k z N4, Installer's Name,Address,and Tel.No. SOT 477 —89-1"j Designer's Name,Address,and Tel.No. CAvEw(D6 L(.C- tJ/A 1153 C-r HA6W Dom' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ` A ax-J o ytiJ exi sTw& 3'ePn e- S y5mm Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 11 Signe Date O� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. (tea l Date Issued ` �-K v� t No. u Fee C THE COMMONWEALTH'OP MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitatlon for Disposal �6pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon k ❑Complete System ❑Individual Components Location Address or Lot No.1 1(9 :5"3 L R vA-1> Owner's Name,Address,and Tel.No. w Assessor's Map/Parcel 3o 'a B ` ' IANMI S I f 5 x6eT��J�LUNE)J�Zj: NA Installer's Name,Address,and Tel.No. J 08-47?-$$Z-j Designer's Name,Address,and Tel.No. CAo�w�yE Ew'Tc"1eF�2cs� �cc. MIAJ 53 C o1.ac1K oE•, ST litA56Atp ` Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date s Title Size of Septic Tank Type of S.A.S. Description of Soil '1 ti Nature of Repairs or Alterations(Answer when applicable) !' A 84t1 1)otJ GU S1t k)& SEf 7`( Q- S VS M-�1 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 lace the system in operation until a Certificate of P P Y P Compliance has been issued by this Board of Health. f Signe Date [Application Approved by Date �f fro Application Disapproved by Date for the following reasons Permit No. (� 2> Date Issued 6�2------------------------- ---------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned X by��P�����- /lt�s ' L&C at f tP S6A6PQW K K )Ab H'IAM)(5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N� )03dated / Al2 Installer i + �iQ S Designer r #bedrooms Approved designflow � / gpd The issuance of this permlit hall not be construed as a guarantee that the system wil lfg�unc,on has designed. _ m Date Inspector ' s --------------------------- ------------------------------------------------------------------------ ------------=- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair7( ) Upgrade( ) Abandon( System located at 1 SE BAoo (`C oA b H VA&j�C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this ermit. Date 7�Z � Approved b r- AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION SBA�r6mk IAM- SEWAGE# VILLAGE N 111 ASSESSOR'S MAP&LOT 30- 0/r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OVO GAl LEACHING FACILITY: (type) 'Cl '5.1 i:'1>t-,� (size) y sTp,-t NO.OF BEDROOMS BUILDER OR OWNER ^Ajcs e4 S7— 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 leachi'�('g facility) Feet Furnished by 1�S�otUh FOr GI A! QI- 10� Aa- A A3_ 133- 1 ► Aq, a 13 O a 3,4- tid' 3 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=307018&seq=1 7/13/2016, J Town ®f Barnstable Barnstable Regulatory Services Department AMMUtCaCh swxNSTA n,srnst.e. Public Health Division r679 �0 m jDrfD MA'I A 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1692 January 13, 2014 Eduardo Raposa Encarnacao % Marcelino & Lioubov A Chua 4 Sunset Lane Luenburg, MA 01462 IMPORTANT NOTICE Map & Parcel 307-018 The Department of Public Works-informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 116 Seabrook Road, Hyannis, MA, to public sewer on or before 6/30/2017. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see enclosure. PER ORDER OF THE BOARD OF HEALTH c Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Eric Q:\SEWER connect\Sample order letters for sewer connection\l 16 Seabrook Rd Hy Jan 2014.doc Town of Barnstable Barnstable Regulatory Services Department ADAmeftC#V I IARNSPABLE. 9q, " 9. �,� Public Health Division �FDMVA�� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1692 January 13, 2014 Eduardo Raposa Encarnacao % Marcelino & Lioubov A Chua 4 Sunset Lane Luenburg, MA 01462 IMPORTANT NOTICE Map & Parcel 307-018 f Public Works informed us that public sewer lines are now available The Department o in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 116 Seabrook Road,Hyannis,MA, to public sewer on or before 6/30/2017. The old septic system must be either.removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see enclosure. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of.Health Eric Q:\SEWER connect\Sample order letters for sewer connection\I 16 Seabrook Rd Hy Jan 2014.doc any, �S UNITED STATES Pd a s ' &rL - i�. �!.' i'•t �istdGla i4 "° & d Sender: Please print your name, address, and ZIP+-4` \Nox 0 � I stable iVls�q� Town earl'D eel ' 4ubl�ca��'S��o26�1 j '173tI '""ilil'r�ifi�Ial�"'3i�f �"If1f:1111 �,1�► =111; ,j1 i i, o Complete items 1,2,and 3.Also complete Ay& item 4 if Restricted Delivery is desired. `- ❑Agent o Print your name and.address on the reverse X ❑Addressee so that we can return the card to you. B. eceived by rinted Na e) C. Date f Delivery C Attach this card to the back of the mailpiece, or on the front if space permits. / Is delivery address different from item 1? 1JY4s 1. Article Addressed to: If YES,enter delivery address below: ❑No Eduardo Raposa Encarnacao _- 4 Sunsetlane 3. Service Type Lunenberg, MA 01462 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑.Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2 Article(T a nsfer from service label) 7012 1010 0000 2851 0 8 0 0$K� PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 pfY,'V:VrI . o •. • 1114.1L'�1 C3 ra F I I - , to CE) Postage $ ru p Certified Fee y i p C rk Return Receipt Fee CA �Postma r L^ p0 (Endorsement Required) Herc,,i Restricted Delivery Fee p. 1:3 (Endorsement Required) W, O rR �09� M Total Postage&Fees $ (y fU� r ' c Eduardo Raposa Encarnacao ' "l 77 'y M1`4 Sunsetlane - - -a Lunenberg, MA 01462 ` Certified Mail Provides: p A mailing receipt fo A unique identifier for your mailpiece fo A record of delivery kept by the Postal Service for two years Important Reminders: c Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. fo 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 USPSe 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'. fo 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. APS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 t - AIL �i Town of Barnstable Barnstable I Regulatory Services Department ,er``aU i RARNRMLE, KASS r Public Health Division ArFO'�``A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 0800 Z Q October 2, 2013 Eduardo Raposa Encarnacao �- 4 Sunset Lane q Lunenberg, MA 01462 So ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 116 Seabrook Road, Hyannis, MA was last inspected on 6/14/2013 by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. ` The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Needs outlet tee on septic tank and-new Distribution box. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH ARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\1.16 Seabrook Rd Hy 201-3.doc • Town of Barnstable Barnstable . "°� Regulatory Services Department ;�`a1n�ly M ' I 1' i H,MASS, Public Health Division V prfDN'"`A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 0800 October 2, 2013 Eduardo Raposa Encarnacao 4 Sunset Lane Lunenberg, MA 01462 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 116 Seabrook Road, Hyannis, MA was last inspected on 6/14/2013 by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: Needs outlet tee on septic tank and new Distribution box. You are ordered.to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH ARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally.passed\116 Seabrook Rd Hy 2013.doc Commonwealth of Massachusetts .. _ Title 5 Official Inspee ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 116 Seabrook Road Property Address:. Eduarado Encarnacao Owner: Owner's Name information is Hyannis MA 02601 6/14/13 required for every Y page: City/Town - - State Zip Code.: Date of Inspection Inspection results"must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness.checklist at the end.of the form. Important:when A. General Information filling out forms on the computer; use:only the tab 1. Inspector: Key to move your cursor-do not... use the return key. Name of Inspector B&B Excavation, Inc; �p Company Name .14 Teaberry Lane - .. Company Address Forestdale MA... ....02644.::: . P City/Town State Zi Code (508).477-0653_ 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 p ursuanto ection .340,Qf Title 5(310 CMR 15.000). The:system: X t Passes ❑ Conditionally Passes . ❑ .Fall. _ ❑ Needs Further Evaluation by the Local Approving Authority „ 7/30/13 y, „ Inspecto ature Date The system inspector shall submit.a.copy of this inspection report o.the Approving Authority(Board of Health or DEP)within 30 days of completino 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 do how the not address hothe system.will perform in the future under the same or different:conditions:of use. : :::: t5ins•303:::: Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-:Pagel of 17: t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Seabrook Road M Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. CitylTown 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts i - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 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 sup ply. pp Y. ❑ 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 El ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. City/Town 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of.Massachusetts W : Title 5 Official Inspection Form . ...... Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 116 Seabrook Road Property Address.. ...... Eduarado Encarnacao Owner: Owner's Name information is required for everyy H annis W MA 02601 6/14/13 page: City/Town State Zip Code. Date of Inspection= C. Checklist . .. :.:Check if:the following have been done:.You must indicate"yes" or"no"as to each of the following: Yes;... No I ® 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 E ® 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 (desig:n) 3 -�Number:of bedrooms (actual): 2 ... DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): .. 330 t5ins•3713;;;; Title 5 Official Inspection Form:Subsurface Sewage Disposal System;•;Page 6 of 17; ; Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: N 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2011 = 188 gpd 2012 = 165 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments °M 116 Seabrook Road Property Address Eduarado'Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 _ page. Cityrrown 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If es volume pumped: Y 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every y H annis MA 02601 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1997 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): >20' 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): S Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 2" t5ins-3/13 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 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. Cityrrown 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 32" 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 16" How were dimensions determined? scour 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.): Tank appears to be in good condition. Installed new outlet tee 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 t5ins•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 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working condition. 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is Hyannis MA 02601 6/14/13 required for every H Y ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: (4) infiltrators ❑ 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.): At time of inspection leaching is dry and appears to be in working condition. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth,& Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal;System Form-Not for Voluntary Assessments M V Seabrook Road Rroperly Address Eduarado-Encarnacao Owner Owner's Name information is required for every Hyannis . MA 02601 6/14/13 page. Cityfown State' Zip Code Date of Inspection D. 'System Information (cont.) Sketch Of'Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two.permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where•public water supply enters the building. Check one of the boxes below: -❑ hand:sketch in the area below 0 `drawing attached separately •. Z► 1r (L �>=C- 0 2 Al 131= ro` 1�2- 28 -B3 -- 3 6'.g y ' t5ins•3/13 Title Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water 1 ® Check cellar ® Shallow wells f Estimated depth to high ground water: > 14'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: 5/19/97 permit dateDate ❑ Observed site(abutting property/observation hole within 150,feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I " I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 116 Seabrook Road Property Address Eduarado Encarnacao Owner Owner's Name information is required for every Hyannis MA 02601 6/14/13 _ page. Cityrrown 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•3/13 r e Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 } ECOJECH Environmental www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) . TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION AP Property Address: 116 Seabrook Road 'hRCEL Hyannis Owner's Name: Lynette Furtado Owner's Address: P.O Box 809 Hvannis,Port MA 02647 _____---- Date of Inspection: May 1, 2004 RECEIVED Name of Inspector: (Please Print) David D. Coughanowr,R.S. 2004 Company Name: Eco-Tech Environmental MAY 0 5 Mailing Address: 43 Triangle Circle Sandwich,MA 02563 TOWN OF BARNSTABLE Telephone Number: 508 364-0894 p HEALTH DEPT. CERTIFICATION STATEMENT: 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature �� � Date:%qY It )-0611 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 1 4' Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1, 2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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,or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The 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 four 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: Mav 1,2004 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 and 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 by 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by 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) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore, the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E)Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd 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 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1, 2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeluding the SAS. located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information. For example,Plan at the Board of Health. Y _ 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 3 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 157 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/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: System not pumped in recent past(Owner) 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: X 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/Alternate 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: Age: 6+years Certificate of Compliance issued 5/28/97(BOH permit#97-248) 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1,2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:_cast iron X 40 PVC—other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:Yes (locate on site plan) Depth below grade: 15 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum thickness: 4 in Distance from top of scum to top of outlet tee or baffle: 8 in Distance from bottom of scum to bottom of outlet tee or baffle: 12 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping recommended within 1 year and maintenance pumping is recommended every 2 years. Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out. 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1, 2004 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):_ pumping:Date of last Comments:(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert. No solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): _ +T 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: _leaching pits,number _leaching chambers,number X leaching galleries,number 1 _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.) Soils above leaching gallery appeared unsaturated. No evidence of surface ponding breakout lush vegetation or other evidence of hydraulic failure was observed. Observation hole dug into stone surrounding drywell units showed no level of standing effluent or effluent contact staining. CESSPOOLS: none (cesspool must be pumped at time 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 or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 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: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1, 2004 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'(Locate where public water supply enters the building) LOCATIONS A B 1 24.5 ft 10 ft 2 28 ft 18 ft 3 17t 345 ft 3 LEACHING z ❑ GALLERY SEPTIC a D-BOX TANK o B EXISTING DWELLING # 116 --� W � Z J W H 3 SEABROOK ROAD NOT TO SCALE 10 a` Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F O PART C SYSTEM INFORMATION(continued) Property Address: 116 Seabrook Road Hyannis Owner: Lynette Furtado Date of Inspection: May 1, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 9+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed X Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators,installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. A test boring was hand augured adjacent to the leaching gallery to a depth of 4 feet below the bottom of the leaching_ gallery and no groundwater was encountered. Applying a groundwater adjustment of 2.7 feet(Index well M1W-29 Zone B,March 2004 reading=8.4)demonstrates that the bottom of the leaching gallery is above adjusted high groundwater 11 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: 116 Seabrook Lane g RE� 1®% �"— Hyannis, MA 02601 j Owner's Name: Miles&Catherine East Owner's Address: 17 Culen Drive OC T 3 n Z u U 1 So.Attleboro,MA 02703 I TOWN OFr,Illy�f'H3��. i Date of Inspection: October 22, 2001 HEALTH DEPT. Name of Inspector:(Please Print) James M- Ford Company Name: .lames M. Ford '' Map:307 Mailing Address: P.O. Box 49 Lot:018 Osterville,MA 026_55-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the 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 Need~er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 26, 2001 The system inspector shall su t a copy of this in ion 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 1 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 Seabrook Lane Hyannis,MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 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 exffitration 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 i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 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 aseptic 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 systein 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: 's 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 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''V 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. p ✓ 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.] No (Yes/No)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 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 Zone 11 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 11 OFFICIAL INSPECTION.FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 Seabrook Lane . Hyannis. MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 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)]. ' rp „ 5_ • ^ Page 6 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000-63,000-gals.; 2001-62.250 gals. 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/sgft,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: None on file- per treatment plant 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 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: May 29197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 BUILDING SEWER(locate on site plan) Depth below grade: 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: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete =metal _fiberglass polyethylene other(explain) If tank ismetal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of " certificate) Dimensions: 1000 gal. - Sludge depth: - 1" Distance from top of sludge to bottom of outlet tee or baffle:` 30" Scum thickness: 2 Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" . How were dimensions determined: Measuring 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.): Tees were present. The liquid level was even with the outlet invert. There were no sums of leakage. Scum and sludge were minimal. _ GREASE 'TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene _other 1. (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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 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: ✓ (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 level. There were no suns of solids or leakage. There were no signs of backup or failure from the leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 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: 116 Seabrook Lane Hyannis, MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 infiltrators with 4'stone(32'x 119 leaching galleries,number: leaching trenches,number,length:, leaching fields,number,dimensions: overflow cesspool,number: Innovativelaltemative system Typetname of technology:, Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The infiltrators were located but not dug up,_There were no signs of backup or failure in the D-box. The bottom to grade was approximately 3'. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 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: 116 Seabrook Lane Hyannis,MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001 Map:307 Lot:018 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. t y a 3 9i - 10 Aa- a8 1-7 133- 3`I Ay- ai ,3., 10 �I Page i l of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 Seabrook Lane Hyannis,MA Owner: Miles&Catherine East Date of Inspection: October 22, 2001- SITE EXAM Slope Surface water Check cellar Shallow wells _ Estimated depth to ground water 12' +/- Jeet (Adjusted High Ground Water Level is 9.7) 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mast describe how you established the high ground water elevation: The bottom of the infiltrators to grade was approximately 3'. Using the Barnstable topographic may and the Cape Cod Commission water contours may, the maps were showing approximately 12'+/-to ground water. Using the Cape Cod Commission Technical Bulletin, the high ground water adjustment for this site(MI W 29, Zone A. 9101)was 2.3. 4 T � This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system;will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to-the system, the inspection and/or this report. 11 , �I t D ' efi U O W �1 G*N s r 2 G1 c ro 1 �- � � 1 c c � c O i IT p 339 578 778 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail(SW revlpe , Sent at um o State,& e Postage 3 Certified Fee Special Delivery Fee r. Restricted Delivery Fee, Ln 0 Retum Receipt Showing to Whom&Date Delivered / V Return Receipt Showing to Whom, Date,&Addressee's Address 0 TOTAL Postage&Fees $ C"1 Postmark or Date LL z-Y' 9�7 Stick postage stamps to article to cover First-Class postage,certified mall fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m +vindow or hand it to your rural carrier(no extra charge). m 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. N 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends it space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the Cr addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li 6. Save this receipt and present it if you make an inquiry. d I Y _ Town of Barnstable .�. Department of Health, Safety, and Environmental Services a►sxsresis. ,� Public Health Division CFO t` 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health February 7. 1997 David Skilllings 95 Constitution Ave. Abington, MA 02351 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at ` � � oad, Hyannis .was inspected on December 16, 1996 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines p of 1995 TITLE 5 (310 CMR 15.00)due to the following: �, 10 /7 N oT9 Ni D • The overflow leaching pit was full of wastewater and was discharging onto the ground. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, the State Environmental Code, Title 5 within (14)fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF E BOARD OF HEALTH T as . McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable e Department of Health, Safety, and Environmental Services M Health Division - fe79• �� 367 Main Street,Hyannis MA 02601 CInstaller ,Offcz-SOS 790.6265 Thames A.McKean t AX: 509-775-3344 Dirodor of Public Health TO: 5 C�- -�0 (Date) . o" Dl1�e. 6 a 3 S ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. 3o7- O � g The septic system owned by you located at 16 ,�Q��Ko Avenue, Circle, Lane, Road, Street in the village of was inspected on i xgo _ by a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: r You are directed to hire a licensed Town of Barnstable septic system installer to sketch a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. The septic system must be brought into compliance within thirty (30), sixty (60), ninety (90) days of your receipt of this letter. You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable title 5(1) ' 'a TOWN OF BARNSTABLE LOCAT?9N -I�e ► � � SEWAGE# VILLAGE V�U ft",VS ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO..OF BEDROOMS BUILDER OR OWNER DATE:—""`C`— 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 i I 1 v � Vi r P 90 r� co �6 - rr' COMMONWEALTH OF MASSACHUSETTS >` /� EXECUTIVE OFFICE OF ENVIRONMENTAL AFF �F `�474yfI 1 DEPARTMENT OF ENVIRONMENTAL PROTECTI C 7 , ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 i1 6 1�9� WELLIAM F.WELD Governor ` CO r,sec I ARGEO PAUL CELLUCCI to STRUHS Lt. Governor Conunissioner --- - - -- - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: l\ b Ge-a b*1tX:zL_ �4 "t*"'t 5 Address of Owner Sv-_tU t►wx S Date of Inspection: klkA4(. (If different) Name of Inspector: �k �SZT� Company Name, Address and Telephone Number: e� !'�^"S�� t �a• O 2-351 ITA RIF ONV STA�TE�MENaT Jrw1T�_ ��aiC 2 ,%k( tAIR'is �PtRj RR, 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority F Its Inspector's Signature: Date: The System Inspector shall submit a copy of t is inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: c Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) A lt.f on RIed Pacer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A t` I 3 CERTIFICATION (continued) Property Address: Date of Inspeetion:'' , B]SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distributi n box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system wi pass inspection if(with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to br en 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board f Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA ETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surfa water Cesspool or privy is within 50 feet of a bor bring vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF H LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNE THAT PROTECTS THE PUBLIC HEALTH:AND SAFETY AND THE ENVIRONMENT: / _ The system has a se/lysis nd d absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply _ The system-has a se soil absorption system and is within a Zone I of a public water supply well. _ The system has a sed soil absorption system and is within 50 feet of a private water supply well. _ The system has a send soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless er analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution acility and the presence of ammonia nitrogen and nitrate nitrogen is ecual to or less than 5 ppm• 3) OTHER (revised 11/03/95) 2 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5e"101==10- Owner: St4Q tNSS Date of Inspection: 1 Lk%o l� D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination-is-identified below..-The Board of Health should be contacted to determine what will be necessary-to-correct -the failure. Backup of sewage into facility or system component due to an 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 e*es&poQI is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: ,�7�l�lt"C.1 Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. Y All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ( Owner: Date of Inspection: l L`%d1C-i 'FLOW CONDITIONS RESIDENTIAL: Design flow: 0-�20gallons Number of bedrooms:42, Number of current residents: Garbage grinder(yes or no):_ - Laundry connected to system (yes or no):tJ Seasonal use (yes or no):��. Water meter readings, if available:_ N)Ip-- . Last date of occupancy: COMMERCIAUI N DUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: T6 nxtl� �P�IJv L". - System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: PE 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: a6 U Q Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: S�;►�11N�S Date of Inspection: SEPTIC TANK: S (locate on site plan) .Depth below grade: l2 Material of construction: j-concrete _metal _FRP—other(explain) Dimensions:I6Gb5;;E44 Sludge depth:_ t '' t Distance from top of sludge to bottom of outlet tee or baffle: 3l Scum thickness:_ Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inver itructural integrity, evidence of leakage, etc.) IJc�ds Qyinn�Ql � .c1 l�u�� voQ w� ovTlpr �YJ�}c211C.`V�QIA\ lh► -;tA 1 j&A % H 1+0 '"-CwMc� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I l(o -- Owner: t Ill"-t, " Date of Inspection: ` `C, TIGHT OR HOLDING TANK: +­1v (locate on site plan) Depth-below.grade: - Material of construction: -concrete _metal -- FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: . Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ W� (locate on site plan) Depth of liquid level.above outlet invert:. Comments: (note if level and distribution is equal, evidence of solids carryover, evidenc of/leakage into or out of box, etc.) PUMP CHAMBER: No (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and ap/rtenances, etc.) (revised 11/03/95) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I ((o Owner: �. 1�►w�5 Date of Inspection: t 2�10 4 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav lion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:(-sal P�� leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of ve etation,etc.) Tk hcN ct t 4-0 5 ct CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: l 1 Owner: -j�t j(t .S Date of InspectionZ`tvl SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 25 2 �.Z 2$ (3Z tam Pf C- 16� � 3 DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: ( &Qe.��0y-, „�,� (revised 11/03/95) 9 ] PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 307 018- - Account No: 217125 Parent : Location: 116 SEABROOK RD Neighborhood: 61AC Fire Dist : HY Devel Lot : 17 Lot Size : . 22 Acres Current Own: SKILLINGS, DAVID G & State Class : 101 BOURASSA, M A & M J No. Bldgs : 1 Area: 1152 95 CONSTITUTION AVE Year Added: ABINGTON MA 2351 Deed Date: 080193 Reference : 8736/088 January 1st : SKILLINGS, DAVID G & Deed MMDD: 0893 Deed Ref : 8736/088 Comments : Values : Land: 21300 Buildings : 45700 Extra Features : Road System: 116 Index: 1453 (SEABROOK ROAD ) Frntg: 80 Index: ( ) Frntg: Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : 012094 Land Reviewed By: Date : 0000 Bldgs Reviewed By: ML Date : 0788 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [307] [019] [ ] [ ] [ ] UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Print your name, address, and ZIP Code in this box Public Health Division Town of Barnstable P.O. Box 534 i HVannis, Massachusetts 02601 % SENDER: :2 ■Complete items 1 and/or 2 for additional services. I also wish to receive the W •Complete items 3,4a,and 4b. following services(for an y ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. 4; ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. d ■Write'Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N r ■The Return Receipt will show to whom the article was delivered and the date .. delivered. i Consult postmaster for fee. a o N a 3.Arti Addressed o: 4a.Arti a Number 9 22 1E d C E 4b.Service Type 0 ❑ Registered ® Certified °C J co Cnn ❑ Express Mail ❑ Insured c ❑ Return Receipt for Merchandise ❑ COD 7.Datflof a iv 0 Z �pZ i i. .Received By: (Print Name) 8.A dressee's Address(Clcr y Nequbsted W and fee is paid) t tire:'(Addressee or&6nt) X a. t� PS Form 3811, December 1994 Domestic Return Receipt TOWN OF BARNSTABLE LOCATION //6 S��-gaol(' R�� SEWAGE # VILLAGE /yV"fv bA.4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) N L.ar/llf U . VO � (size) NO.OF BEDROOMS BUILDER OR OWNER 5 PERMFT DATE: S -I If-�7 COMPLIANCE DATE: �-a - Separaton 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 - , .� zd C* , o 0n TOWN OF BARNSTABLE ILIL'CATION` �� Se.4�rovk IA^A- SEWAGE # �� ay VLAGE �y46/11 S ASSESSOR'S MAP & LOT 30� �l �%�-INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY GA LEACHING �• LEACHING FACILITY: (type) y T��,�><ia�il (size) 7 S-rdAk NO. OF BEDROOMS 3 BUILDER OR OWNER M,Its C ST 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 leachi�g facility) Feet Furnished by suc v�o� �or Gl A 81 - ro Aa- ag 8a� , A3- (� „ IB3- 3y`y `- - - I i Ay, g i 3 O 1a fay. yo" 3 TOWN OF BARNSTABLE z.CY-_ iION .>�b R6 SEWAGE # 77, a �`s .LAGE_14!J"tV 5 m/"� ASSESSOR'S MAP & LOT 3D2- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 16M_ LEACHING FACILITY: (type) SOt'k-9 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ��—I °�`1'7 COMPLIANCE DATE:. a 9 `7 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 . `_'�-- 0 �. >�. � � � �� w � -b �,� - � '�--�� �= a P, -.. � � � a � �, „�, � •�, , , . E 8 -' ty C� No. q/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ofpprication for 30igpoar *p6tem Construction Permit Application fora Permit to Construct( )Repair( )Upgrade(Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.i 1 I,- ��� Owner's Name,,Address and Tel.No. Assessor's Map/Parcel —SO—7 —p k Installer's Name,Address,and Tel.Nob. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 'S �� 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 t Nature of Repairs or Alterations(Answer when applicable) Sw r=i L-r rc_,tv< c &v-e— o S i✓J>r z!// 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 nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has bM his Signed A Date 5 "1 Application Approved by Date 64,IQ Application Disapproved for following reasons Permit No. 7- Date Issued �( r No. V _ Fee J 0 THE COMMONWEALTH OF MASSACHUSETTS -- A. Entered in computer: l - PUBLIC HEALTH. DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes Y 01pprication for Migpooal *p!tem Cone;tructton Permit Application fora Permit to Construct( )Repair( )Upgrade,( Abandon( ) ❑Complete System ❑Individual Components ~ Location Address or Lot No. % (Q 6cL A,, Owner's Name,Address and Tel.No. Assessor's Map/Parcel IrI. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - �1(V11p-Ga�.S�P'1L ao PWx�cr /� , As Type of Building: Dwelling No.of Bedrooms 3 Lot Size, sq. ft. Garbage Grinder( ) Other Type of Building No.;off Persons Showers( .) Cafeteria( ) Other Fixtures ' Design Flow 'J gallons per day. Calculated daily flow, gallons. Plan Date Number of sheets .Revision Date Title 4 Size of Septic Tank EX l 9-t t 1600 y4f 16-w Type of S.A.S. Description o€Soil S 14 t Nature of Repairs or Alterations(Answer when.applicable) S w SV VA << Uv✓ ►�7 C, �c., T�- �, Sw i L7 f��r`v 5 t �v-e.- ow S%✓JE -� �/�� `� r✓ Date last inspected: Agreement: s 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 vironmental Code and not to place the system in operation until a Certifi- .- cate of Compliance has lb is is B - Igal tt. Signed Date .�1 r1_cl:;7 Application Approved by �� Date 5 -Iq Application Disapproved for tfd following reasons Permit No. Date Issued, —.— ------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that t site Sewage Disposal System Constructed( )Repaired ( ) Upgraded Abandoned( )by ��o���.- ybe�'�S M"t 0-"AI E at 5��. I o o o-b yvi S Y^to i has been constructed in accordance with the provisions of Title 5 and the for Disposal.System Construction Permit No. -a 6 dated Installer Designer The issuance of this e t yqjbe construed as a guarantee that the system will f 'on as designed. Date ' / Inspector ♦� --- ---—---—————— r No. Fee k` U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpozal *pztem Cbn5tructiott Permit ' Permission is hereby'granted to Construct( )Repair( 1/)Upgrade( )Abandon( ) System located at i� 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 permit. Date: - 1 7 Approved by N r % 1 � / NOTICE: This Form is to be used for the Repair�o Tailed Septic Systems Only CERTIFICATION OF SKCTCII AND APPLICATION FOR A DISPOSAL NVUIZKS CONSTRUCTION1'LRMI'I' (WITHOUT DESIGNED PLANS) 1��,� =✓`FS , hereby certify that the application for disposal works construction permit signed by me dated S fay`c7'7 , concerning the property located at /16 Se,bv-ov4 1V 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: DATE: `y—�7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j:ccrt ��^ � �� �,.. �. '' a Q �LDCL�TION �' /moo /._ S9EWQ,C,E _PER.MIT tJO._il 11�l-ST_QLL-ER�S_1.1�t�/lE_�_A-D.DRESS_ -- Ala,-s o n s /1/,%/s, �Y/ifs: - - _ —D ATE_CO-MP-LW,ACE ISSUED.:'A6 7 ��. '' � b` i'� �� Q � ,�, �- , . �_ � �_ o 0 � d o �, � � �� *_ , -�� No.............. Fmic......Id.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. . ..........OF......................................................................................... Appliratiun -fur M-4puuttl Works Tututrurtiun Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: @ N . ...-•---•-- � Locn- ddress or Lot ... '.......... -- ........ ---------------•-•--------------•--..........-•-....---'------•-•---•-..._...................... caner �-�� Address ....--''. . ................................ ........................................ nstaller Address UType of Buil g �� Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---- -_ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------- -------------------•------•---------------------•-•-•----------------------------------------------•----------------------•--.------ w Design Flow...... __._.�j.a--.--_.gallons per person per day. Total daily flow------------- .............---gallons. r4 Septic Tank—Liquid ca)acit�C1-/./gallons Length................ Width................ Diameter _ _-_----..-..---__ Depth.. --_ -_--. Disposal Trench—No...( _...._. Width---- ------------ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total lea uug•a a._._...._...______sq. ft. z Other Distribution box ( ) Dosing tank ( ) `I- Percolation Test Results Performed by............. ........................................................ Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...--------------------- IX4 Test Pit No. 2............:...minutes per inch Depth of Test Pit-------------------- Depth to ground water............--.-_-_-..-- �' -•-------------------------------------Q------t---------------- -------•-- ...... ... O Description of Soil tf-` R "� ------ --------- a------`- < - x --------------------------- -------l 1 .�.--•--';��...... -� . c, - w V Nature of Repairs or Alterations—Answer when applicable---------------------------------------------.-------------------------------------------------- --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------­----------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issue�by t board of hea th. �1 ................................ Date Application Approved By-------------------- -------/-- ---- Date Application Disapproved for the following reasons-------------------------------------------- -...-------------------------------------------------------------- ----------------------------------------------------------------------------------------------------'---------- ---•"•--------------------•---------------------------------------•............... Date PermitNo--------------------------------------------------------- Issued........................................................ Date ---__ -_-_-_-------`------------------------------------------------------------------------_� F>nc.....,1�,�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... _._ ... ... .................OF..................................... ......_...............---- ----........-------- Apphratiun -fur Dispoii at Vorks Tonotrurtion Vrruiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... 0............1...--..........----'-•--------------•-------•---.........-- e Loc i n•Addres or Lot No. }Owner Address Installer Address Q Type of Buil ng Size Lot............................Sq. feet Dwellin No. of Bedrooms_________________________ V g— -Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building __. .r. ','^ .... No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. W Design Flow..... ...... _I)........gallons per person per day. Total daily flow------------Z__2-.0 2___oA................. x Septic Tank—Liquid c p� � _ ..�gallons Length................ Width..___..-- .._.. Diameter_____...._...._. Depth ..______.__..- Disposal Trench—No.�................. Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No_____________________ Diameter..........-......... Depth below inlet_______________._-_- Total lea ]ling a-_-___--_________sq. ft. z Other Distribution box ( ) Dosing tank Percolation Test Results Performed bY........................................................................... Date----•-------------------------------._.. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...-_-_____-___-__-_---- '' LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-._..._-_..._________ Gfi --------- r--- ----------------- ----- ---- -- -- ---- Description of Soil ] -... f1 ` . C'.u------- Q -------GLc'- '`f. %f (� W U Nature of Repairs or Alterations—Answer when applicable---------------_____..........................................................----------------_ ---------------------------------------------------•-----.---__--_ -----••---------------•-•------•-----•-----------•-------•-------•--•-----._....------------------.._........--••----------....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has/bDis uer�by t e board of hea th.gned.. Date Application Approved By----_-------------- -•-----•-- t i.r[�-!.. -�� ...... ' Date Application Disapproved for the following reasons: --- ....----•-------------------•--._.......---•...----•------------- ----------------------------••--•--•--••--•-••----------•--•-------------••-•-•-----•---------------.....-•--•-••-•-•---••------•---•-••--------••-•---------•----------•--......--••--------------•-•-- Date PermitNo.._..------•-----------------•-------------------------.. Issued........................................................ Date t 1 THE COMMONWEALTH OF MASSACHUSETTS i BOARD Off )HEALTH ,/�!\......O F............... .. ................................................................ Trrtifiratr of (GIumlilittatrr THIS IS TO ART. , That the Individual Sewage Disposal System constructed ) or Repaired ( ) by �4.�--•-- ---------------------------------•--------- ----------------------------------------------------------------------- ............................. nslall r /(%'c 1 has been I,, stalled in accordance with the provisions of ' rtic XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N ___________________ dated../U_..'__a__�...7--_ `.----...-.- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS UARANTEE THAT THE SYSTEM WILL fUNCTION SATISFACTORY. DATE-----------} ;.?........ ................................ Inspector... ...................................... THE COMMONWEALTH OF MASSACHUSETTS a BOARD F HEALTH r 7 a-� t / .....�.,t�./.�-,.......OF........ .. .. ....1 -- - --,-........-------------------•----.......... /� No. �f-------- FEE---l-.-- ............ �i Vo a1 ork >QJo urtion rrmit Permissio i ereby granted----- __,6._ _ . .•--- r to Co>is uct or(Repair�( ) n/Indivi 1 'sewage Di sal System at NoVZ 7-----/-7--- ,fi7.i/��-1�------- :.--------.. . .� . st,-eet . as shown on the application for Disposal Works Construction Per Dated- ._---__ ' 7 1� ----••------------------ ---------------------------------- -- - ----- -- / w oard o`Health DATE-----�- -------�---------------------------------•----------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 7 -m d 22_ L { F , R"ARC1 Gv� A. �„1 �• 6 BAXTER i 3 C.C-2 T 1 F I GC5 IPL.o`r Cat ,A :1 Ma 24048® .l k &Qa�p� L ocA"C'i o� 1 1-4`E ��1 S ! SS Z Zn 'DAY OCT i� 1 qI w ocv�cJ Cam.? orz rF L >T 1" t 1'-A k� 3ooK. 72. PAUS d5 ZAws or r,4 S- ZU.15zE2et> LA-.A StJq►/E:joa5 Ost"'axWlLi.G AAASS Pert Tj 0441M . IPA aL.. Leo),.)44,2 o