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Home My WebLink About0124 SEAGATE LANE - Health 124 SEAG ATE LANE, HYANNIS A -249 137 e a I OLIf� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 124 Seagate Ln Property Address ' Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis MA. 02601 8-10-11 required for every Y - page. Cityfrown l 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. A. General Information 1. Inspector: - Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr ., Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 $13971 Telephone Number License Number LU N B. Cification 6r cry I certifythat I have personally inspected the sewage disposal system at this address and that the �; P Y� P 9 P Y information reported below is true, accurate and complete as of the time of the inspection. The inspection c was performed based on my training and experience in the proper function and maintenance of on site sewage dBposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5('3�10 CMR 15.000).The system: r ®4Easses ❑ Conditionally Passes ❑- Fails ❑ Needs.F rth valuation by the Local Approving Authority nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or.different conditions of use. • I t5ins•11/10 Title 5 Official Inspection Form:SubsurfaceTSegeDisposal System•Page 1 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check ,4,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: System is in good working order with no sign of failure. 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•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts ` o Susurface Ti Sewage tle 5O�ificiaol Inspection Form Disposal System Form Not for Voluntary Assessments 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y -❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 0,. 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M y 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 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: Ej JZ 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 F 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. El ® 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, your must indicate either` ps"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 ❑ 0 . 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-11/10 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 124 Seagate Ln Property Address Bank Owned (Contact David Halt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 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 ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems. The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 124 Seagate Ln , Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis _ MA 02601 8-10-11 page. City[Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No .Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No 6-2010 Last date of occupancy: Date Commercial/Industrial Flow Conditions: , Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,.etc.): Grease•trap present? t ❑ Yes ElNo . a . Industrial.waste"holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter.readings, if available: t5ins•11/10 , .., , r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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 Elg t tank. n Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 l 0 Commonwealth of Massachusetts W Title 5 Official ,,Inspection Form o Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 4„M 124 Seagate Ln ; Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis . MA 02601 8-10-1.1 required for every H y • page. Cityrrowm State Zip Code Date'of Inspection D. System Information (cont.) Approximate age of all components,date installed (f known) and source of information: 2000 Were sewage odors detected when arriving at the site?' ❑ Yes ® No Building Sewer(locate on site plan): , Depth below grade: _ # - , y 20" feet Material of construction: y El cast iron ® 40 PVC ' ' ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12"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: } ;+: _ ,.; 1500 gal Sludge depth: 12" t5ins•11/10 ., Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 9 of 17 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. Cityfrown 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 20 Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape 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 is in good condition with baffles installed. Grease Trap (locate on site$lan): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name , information is required for every Hyannis MA ` 02601 8-10-11 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: -r 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•11110 F _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 F. Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. Cityrrown 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.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 M 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name r. • k information is required for every Hyannis ti MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of pondingi damp soil, condition of vegetation, etc.): Infiltrator field in good condition with no sign of back-up into d-box or surrounding stone. 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•11/10 { - 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 ' M 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M . ' 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owners Name information is Hyannis required for every y MA 02601 8-10-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Cf:: D G o Q 3 0 _,0_ 4/()1 t t5ins-11110 - Title 5 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 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 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 124 Seagate Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 8-10-11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ri Tt3Wld OF B�ItNSTABLE le SEWAGE # VILLAGE !Ti a�/! S rI ASSESSOR'S MAP&LOT INSTALLER'S NAMF_&PHONE NO_- ;l � )Z t f SEPTIC TANK-CAPACITY LEACHING PACIt=: (type) � ''� 1- � tJ'c� {W (size) NO.OF'BEDROOMS 3 - -- j5UILDER OR OWNER PERMITDATE: CO&PLIANCE DATE: Separation Distance Between tbe: Maximum AdjustO 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 I ping facility)) s Feet Furnished by L r� O h o � �) O n Ui W y TOWN OF BARNSTABLE C Ga LOCj� 'ION 1d2!1 Le 6 aZe_��f� SEWAGE # r ',VILLAGE .i/r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. C 4 Y)e .SC�i G L SEPTIC TANK CAPACITY %So 0 LEACHING FACELITY: (type) 1,,/ 6ZZM 7O- k (size) NO.OF BEDROOMS `i3UILDER OR OWNER PERMIT DATE: 00 COMPLIANCE DATE: 7 W . P� 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 .z e ' e O �► n Uj W TOWN OF BARNSTABLE LOCATION `�-� C��c�„ ) SEWAGE # VILLAIE ASSESSOR'S MAP & LOTa� t3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= ItSROW LEACHING FACILITY: (type)Gov 1 (size) Sb4 P4r- k �r Tcuc, 0.OF BEDROOMS �T BUILDER OR OWNER \1)oW MWffFVATE: _COMPLIANCE DATE: Separation Distance Between the: LO Maximum Adjusted Groundwater Table and f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �R �C� Ir S N � � w N r J orown of Barnstable Health Inspector pF tOyj� Regulatory Services Office Hours 8:30—9:30 �.� Thomas F.Geiler,Director 3:30—4:30 * Public Health Division •ARNSTABLE. » Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE Date:February 15,2012 1. General Information: Size of Property.75 acre Address: 124 Seagate Lane Hyannis,MA 02601 Map 249- Parcel 137 Name:James H.Pearson Phone#: 508-815-9702 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms? eS If es,how many? �-r]� ACC c-sw YL.Q -kvj pv-opeYTy owner wilt r cl uct. : of � dyboms 1r, v-ne ir, house arec`JJ0 2. 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is.the dwelling connected to public sewer? No Ifthe dwelling is connected to public sewer,,skip questions#4.through#9 below. 4. Location of dwelling is INSIDE . a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE a Zone of Contribution to public supply wells?WP O 6. The dwelling is connected to PUBLIC WATER? t O 7. Is a disposal works construction permit on file? YES or. NO -rt 8. If yes,how many bedrooms were approved according to this permit? Bed dooms. - 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 77 an co rn 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO --- -------- ------------------------------------------R OFFICE USE OFFICE USE ONLY �000�� e Public alth Division has no objection to bedrooms at this roperty. Special Conditions: we,( �4 � S 0;e- an jolei',S Signe � Date: �,� -'own of Barnstable Health Inspector ' 'THE roy, Regulatory Services Office Hours 8:30—9:30 Thomas F.Geiler,Director 3:30-4:30 i BARNSTABLE, * Public Health,Division 9 MASS. g 16 3g. �0 �'Arfn.59 Thomas McKean,Director 200 Main Street,Hyannis;MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT- SEPTIC QUESTIONNAIRE Date:February 15,2012 1: General Information: Size of Property.75 acre Address: 124 Seagate Lane Hyannis,MA 026,01 Map 249- Parcel 137 Name:James H.Pearson Phone# 508-815-9702 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms? 2S If es,how many? 0 ACC C'S So pv -vper17. owrticr wit1 Y cl UCt_ :t3 o-F . eclYPOmS In �-»ain hdus�C arec, 2c. How many bedrooms total are proposed at this property(including the amnesty.unit)?. 3, 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight=edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. t 3. Is the dwelling connected to public sewer? (� If the dwelling is connected to,public`sewer,,skip questions#4 through#9 below: 4. Location of dwelling is INSIDE -'a Saltwater Estuary Protection Zone? 51. Location of dwelling is INSIDE a` Zone of Contribution to public supply-wells?WP 6. The dwelling is connected to PUBLIC WATER? 7. Is a disposal works construction permit on file? a' YES or NO. 8. If yes,how many bedrooms were approved according to this permit? B�'doms. r 9. Were any building permits obtained for construction of additional bedrooms? YES r NO �? 10. Is.there an engineered septic system plan on file at the Health Division? _ YES. 0,4 . NO a. 11'. Has the septic system been inspected by a DEP certified inspector within the last two years? YES 0 NO p ----- ------ -------------- ---- ----- --- -------- ---------------------- ---- -------------------- --- g.a.'t FOR OFFICE USE ONLY The Public Health Division has no objection to, bedrooms at'this property. Special Conditions: Signed: Date: ' t 3 .f Q��111 - 1 f J • ' r it •art--.z Ij } ; rb if i I J " r i I t ' Alp L 1Ces�i a -ri I ji -FIN i 'VA ¢ 3. fR �v�l` R�aea .3 Zrl a{�3zt` � f� tvCG} _htF�. O— �� I AsBuilt Page 1 of 1 ' TOWN OF BAKNSTABLE LOCATION 1.2 Y _�P�(�n Ze SEWAGE# wV VILLAGEq.,i.ri i S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY %Sa o LEACHING FACILITY: (type) /,-j 47M 20if S (size) NO.OF BEDROOMS BUILDER OR OWNER -PERMITDATE: OO 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 , C k oa 11.2 S http://issgl2/intranet/propdata/prebuilt.aspx?mappar=249137&seq=1 11/20/2013 AsBuilt Page 1 of 1 s TOW14 OF L BARNSTABLE LOCAT 4 .. C1ION 57 n le- , SEWAGE# VIILLAGEEg✓t n t-3 ASSESSOR'S MAP&LOT INSTALLER'S NAME PRONE NO_ SEPTIC TAINT{CAPACrrY LEACI3ING-FACII.ITY:(tax) ►•t .` fG (size) 41 NO.'OF BEDROOMS— BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE- Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leac+ing Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist an site or within 200 feet of leaching facility) Fee! Edge of:Wetland and Leaching Facility(If any wetlands exist within 300 feet of I Ming facility) Peet tSGUGrG✓H / �G� ' Furnished by i p i o Q-d-7 9 -d_ 410, z:. b http://issgl2/intranet/propdata/prebuilt.aspx?mappar=249137&seq=2 11/20/2013 7111 AL VAN r^e S � yt s K.f� x t Ss'T'aa I�V.1Y . All rb T O� ^_ 5►,: Gr3ANI 35 O I F d 1 y/,k 4 with is FFT . ,. - * � F.t� �'� �;fr� E � �� .a.�y'k � ,:.��-tom^" �,"wS „�',.�.k:�,.} � •,� �` �,/v • ojoy., Of- 21 oil rEms ON * Ys met - t .. ;.,, .. .�..•L;.... „„x. w� ,,.'ti.w .:_.-'"s.-�--a, �.:.�.. M.. �r,a .o.,, ��'".`�a�„„.s y; :� „^t,._.�.�+ .. _� .�.��«.r,.�' r tl " v j ,v S I r 17 x IT n max- +�.� f "� f • ,l' �eDRoon� Z - -�• CIOr t J@i ' t UIt_N AA _ Be st IT a o� p� toe �j i " s } i �� rjAS�C� ,ice -IF, was 2al !I Ih " �� s�N Vbye�H N7 34v4 (wn ' h z - j 1 --�• �{ Ida ! fit rs o ro y 1 CA r b. \� I AsBuilt Page 1 of 1 '!'OWN Or BARNS'I'ABLJr LOCATION S'o c (�a�,�_ SEWAGE # VILLAGE/ "�y ^� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. C SEPTIC TANK CAPACITY /So o LEACHING FACILITY: (type) 70k a (size) NO.OF BEDROOMS ` BUILDER OR OWNER VERMITDATE: DO 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 ACC Q t) D 4 http://issgl2/intranet/propaata/prebuilt.aspx?mappar=249137&seq=l 3/15/2012 Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) $�mplete System ❑Individual Components Location Address or Lot No. i� C J� � �'Va Owner's Name,Address and Tel.No. Assessor's Map/Parcel S (Acy dery ";k%-kcI- i`�7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &-1 S S V� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures, Design Flow U gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank ---Type of S.A.S. C Description of Soil; V c,o +4 �1 }O c✓�1 J Nature of Repairs.or Alterations(Answer when a plicable) csn ,G t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has y d alth Signed Date '� `� Application Approved by Date S =1 112— e, Application Disapproved for th following reasons Permit No. .aaL ! I S' Date Issued TOWN OF BARNS/TABLE LOCATION Z2 Y �� (�a�� / _ SEWAGE # VILLAGE ASSESSOR'S MAP & LOTJe_ / INSTALLER'S NAME&PHONE NO. 19�7 C-1.14 i C j SEPTIC TANK CAPACITY /.So O LEACHING FACU rrY: (type) l,.j ��/��(. 70,k Z (size) NO.OF BEDROOMS i BUILDER OR OWNER PERMITDATE: O1J COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet I . Private Water Supply Well and Leaching Facility (If any wells exist j on site.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet I. Furnished by -._..._.._.. ..._,_,. 53 i I I I I o .fF No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ! Yes - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Zipplication for Mitpool *p$tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(''Abandon( ) 7Wmplete System ❑Individual Components Location Address or Lot No. C U1 v` Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No._cf7Bedrooms _Z_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z`? i ; gallons per day. Calculated daily flow �?��-, gallons. Plan.,Date Number of sheets Revision Date Title Size of Septic Tank T>ta f- - : , , < v Type of S.A.S. Description of Soil t : Nature of Repairs or Alterations(Answer when applicable) , Date.last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system yin operation until a Certifi- cate of Compliance has be_ =�Zen,issue44y-this_B.aWdofalth. Signed Date .�Z 2-A-) Application Approved by Date T� G Application Disapproved fort folio ' g reasons Permit No. Date Issued C1 ----------------------------- "-T.r-—3------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS � ; Certificate of Compfian&" THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by & 4 at C has been constructed in accordance with the provisions o Title 5 and the for Disposal System Construction Pe 't No. dated Installer Designer r The issuance of this permit shall not be construed as a guarantee that the system w'11 function as de� ,ned. Date Inspector ector "T ----------------------------------r----- No. Fee — / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigogaf *p.5tem Congtructton Permit Permission is hereby granted to Construct( )Repair( )Upgrade( �_�Bandon System located at `-�-C o- (� - LA, —� 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:�T --, Approved by N S- t 1/6/99 NOTICE: This Form Is To Be"Used For the Repair Of Failed Septic Systems Only. . CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 3-\_- (74) , concerning the property located at t�� 5�� 'r��'� t' i meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. "• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system W/There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] /'If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation d+the MAX.High G.W.Adjustment.t DIFFERENCE BETWEEN A and B SIGNED : DATE: 3—\ [Please Sketch propo d plan of sy m on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert ,� �� i { �, i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AF DEPARTMENT OF ENVIRONMENTAL PROTECN'�UC ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 °~ ;,04* 199CJ p j OFB . �` hFq[Ty FPTTge(f WILLIAM F.WELD TRUDY COXE Secretary Governors �+ ARGEO PAUL CELLUCCI DAVID B. STRUHS Commissioner Lt. Governor ®� G,p �`�G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM fj 1 PART A Lo T- 1 3'1 CERTIFICATION a ), �C 0�C_t� Property Address: 1 vq C`- lt 1 �r1tJ(�*tiS Address of Oµmer: Date of Inspection: .-1�Z`��G�o (If different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address: i', r�r ,x Telephone Number: 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 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 Fails r Inspector's Signature:'AxtA Date: The System Inspector shall submit a copy of this 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 SUNBIARY: 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. COMMENTS: - yG�an O A S ' Wall J 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. Indicate yes, no, or not.determined (Y, N,or ND). Describe basis of defetmimtion in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal• is cracked• structurally unsound, shows substantial infiltration or exftltration, 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 04125/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: Date of Inspection: J BI SYSTEM CONDITIONALLY PASSES (continued) i Sewage backup or breakout or high static water level observed 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 the Board of Health). Describe observations: 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 broke 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 HEAL Conditions exist which require further evaluation by the Board of H Ith 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 DE RMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HE TH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface w ter _ Cesspool or privy is within 50 feet of a borderi vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF ALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTI NING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AtiD SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil ab orption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil bsorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and so' absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and s it absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fa ility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine dist nce (approximation not valid). 3) OTHER Pa e 2 of c0 (revised 04/25/97) P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criter'/asdefiined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to etermine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloa ed or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground /oan e waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert doverloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availme is less than 1/2 day (low. Required pumping more than 4 times in the last year NOT ue to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System. cesspool or rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet f a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zon I of a public well. Any portion of a cesspool or privy is within 50 f et of a private water supply well. Any portion of a cesspool or privy is less than s feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well as been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compound , ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the fol owing: The following criteria apply to large systems in a dition to the criteria above: The system serves a facility with a design flow f 10,000 gpd or greater (Large System) and the system is a significant threat to public i health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of surface drinking water supply _ the system is within 200 feet o a tributary to a surface drinking water supply the system is located in a nit gen 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 04/25197) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: `Z;A Owner: boJV_oJ Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or 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 havebeen 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. 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: b::y' Lc, Date of Inspection: 1 FLOW CONDITIONS RESIDENTIAL: Design Flow:-A71ta g,p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents:, Garbage grinder (yes or no):_� Laundry connected to system (yes or no): Seasonal use (yes or no):—L� Water meter readings, if available (last two (2) year usage (gpd): tQ) Sump Pump (yes or no): t3 Last date of occupancy:—�-� QQzkmcro COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Rallons/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 INTORMATION PUMPING RECORDS and source of information: �CIYY��t�, � to u�c �.�y1' �G Q�,c_�C.��,�s. •�,�t tN� �ti UvJr.f-�i(' System pumped as part ot inspection: (yes or no)�V rT- If yes, volume pumped: Gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: % t Sewage odors detected when arriving at the site: (yes or no) (revised 04125/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _oche explain) If tank is metal. list ace _ Is age confirmed by Certificate of Compliance Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or affles. depth of liquid level in relation to outlet invert. structural integrit}'. evidence of leakage. etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fib glass _Polyethylene ,_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee o baffle: Distance from bottom of scum to bottom of ou et tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition f inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity. evidence of leakage, etc.) (revised O4125197) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspectio ) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(expl 'n) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in workine order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee• condition of alarm and float switches. etc.) )ISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids ca/,over. dence of leakage into or out of box, etc.) PUDZP'CHAMBER:_ (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 o pumps and appurtenances, etc.) (revised 04/25/97) P2ge 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IIYFORMATION (continued) Property Address: \2q �`-/ft�'--2_ Owner: 11 Date of Inspection: 12� SOIL ABSORPTION SYSTEM (SAS): 5 (locate on site plan, if possible. excavation of required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fields, number, dimensions: overflow cesspool, number: tiA X b t Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding,,cond' ion o vegetation, etc.) 1 b�( CESSPOOLS• (locate on site pla ) Number and configuration: Depth-top of liquid to inlet invert: Z'K11 Depth of solids layer: Cti" Depth of scum layer: ':k« Dimensions of cesspool: ' 11 Materials of construction: ft(,ic } Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 1.1RL� yQtQ ty Comments: (note condition of soil, signs of hydraulic failure, level f pon ing, con ipion o vege Rtion, etc.) _ SOXv v 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 04/25/97) Page 8 of 10 f , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add r s: ,Z�� {�• Owner: � �� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1(0 (revised 04125/97) Page 9 of 10 • J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:�Izy�yb Depth to Groundwater IUFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) �iS, 1o9� 3 (rev' /2 / 7 Page10of10 used O3 5 9 1 �I KE Certified Mail#7008 3230 0002 5178 0066 Town of Barnstable ST"M Regulatory Services $ArFo �a`� Thomas F. Geiger, Director Public Health.Division Thomas McKean, Director 200,Main Street, Hyannis, MA 2601 Office: 508-862-4644 Fax: 508-790-6304 - n March 28, 2011 Wells Fargo Bank,N.A. 1.000 Blue Gentian Road Eagan, MN 55121-1663 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE The property owned by you located at 124 Seagate Lane,Hyannis, MA was inspected on March 25, 2011 by Town of Barnstable Health Inspector Timothy B. O'Connell, R.S., because of a complaint. The following violation of the Town of Barnstable Board Code was observed: 353-1 Responsibilities of Owners: It was observed that property had household garbage and debris strewn about property. You are directed to remove all of the above mentioned items from this property and dispose of them properly. This violation must be corrected within fourteen (14) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH �I T omas A. McKean, R.S.; CHO Director of Public Health C Town of Barnstable Cc: Logic Core QAOrder letters\Refuse\124 seagatet.doc f UNITED-STATES POS7ALSt�tft�f= `'`' F #assufait w,, `'PoSYrje$w eeSaid p-10 • Sender: Please print your name, address, and ZIP+4 in this box • I r s 01 FsainsHble a Healtfi Division 20O Main Stine,,, a•. Hyannis;iV1A 02601 I .. MA 2; SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signatu item 4 if Restricted Delivery Is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. pate of elivery ■ Attach this card to the back of the mailpiece, /"'A1 or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Wells Fargo Bank,N.A. 1000 Blue Gentian Road Eagan, MN 5 5121-1663 I 3. Service Type I V94-Artifled Mail ❑Express Mail ' _ ❑Registered �Retum Receipt for Merchandise I ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2.-0'11 umber 7008 3230 0002 5178 0066 sfe � r from service label) 381m, February, 2004 Domestic Return Receipt 102595-02-M-1540. 103 e ��•' ; c / ; 171 +. 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