HomeMy WebLinkAbout0149 SIXTH AVENUE (HYANNIS) - Health �-
149 SIXTH AVE., IHYANNIS - Y
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for Misposai *pstrm Construction permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) []Complete System ❑Individual Components
Location Address or Lot No. Y,4 Ow is ame,Apddress and Tel.No.z�l
jz�c�Gc�j6G�
Assessor's Map/Parcel ;?V
Ins ller's Name,Address,and Tel.No. 3— ems' �8as Designer's Name,Address,and Tel.No.
-//, y e-00d Cock c-' iC
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)
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.
Sign Date 6 !Q
Application Approved by Date 61
Application Disapproved by Date
for the following reasons
Permit No. L ��^ Date Issued V
r -tea�_�Y }r...;v: �.,,� f+.;.. _,_ K �.�,,.srvw;,,y. .K ,g,y.."'r .r.tr. irMs,. ;"" ;�, •Y `n...: ,r.-pyE,�,c..{�--r �.v ., ...,� ? .'
f
t
N,—_,-)�) Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:T
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for -bisposal *pstrm,Cotisttuttion Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /!Yf' Owner's�1ame,Address and Tel.No.?'�1' Y3 p " d 9l
/S 41/Q 15�4'dc�llC�
Assessor's Map/Parcel /,I f' 7
Installer's Name
Address,and Tel,No. 3 =prs` ?g. �' Designer's Name,Address,and Tel.No.
�•fv.�iPi i✓ rT. �/ Yam►-�-�,4
Type of Building:'
.Dwelling. No* .of Bedrooms
� Lot Size, sq.ft. Garbage Grinder( ) -•I
f-
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. axy
Description of Soil ,.~"
Nature of Repairs or Alterations(Answer when applicable)
-Date4ast 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.
Signed.-- -tee_ . Date 6%/I;''
Application Approved by "' Date /
Application Disapproved by' Date
for the following reasons Y'
a
Permit No. (••;•;�0 f�-^� � � Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificated Compliante
TIES IS TO CER�TIIFFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�i'� Upgraded( ) '�
Abandoned( )by
at ��Q ,l`i,C7rh �t.N h�s•�? cr� has been constructed in accordance'with the provisions of Title 5 and the for Disposal System Construction Permit No A'7&ated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit sh•lll not be construed as a guarantee that the system{,will as designed.
Date 11)1 tl f� Inspector`w,,-
- -----------.-------------.--:.------ ------------------- -- ----------------------------------------------------------- -----
?
No. c�"�=i l� /��' V - Fee �" a�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at _i,"P Xy, _�yE? /S�� �-,• ., i •
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 perm .
Date to
.�{� �� � Approved by
41
ti
-�tKE ram,
Town of Barnstable Barnstable
Regulatory Services Department AHffmdcaCdy
BARNSTABM
Y� b q Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 9972
June 11, 2018
CALAUTTI, SALVATORE & OLGA
3 ANDREWS CIRCLE
WAKEFIELD, MA 01880
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 149 Sixth Avenue, Hyannis, MA was inspected on
05/18/2018 by Paul Martin, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Distribution box needs to be replaced and the garbage disposal must be
removed.
You are ordered to repair or replace the septic system within two (2)years 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 T OARD OF HEALTH
Th as Mc ean,
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\149 Sixth Avenue Hyannis.doc
THE r,
°* Town of Barnstable
� A RHLTlA7� 4
Regulatory Services Department
Ea r�
Public Health Division
200 Main Street,Hyannis MA'02601
Office; 508-862-4644 Richard Scab,Director
FAX, 508-790-6304 nomas A-McKean,CEO
Feb 6, 2007
Rev. 5111116
DEADLINES T.O REPAIR FAMED-SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
'An`Z'marked in the ❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA s
❑Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe. :.
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool '
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable wafer quality,analysis.*(This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
q Single Cesspool
PAny"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline: '
WSEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601 aA�
Property Address c_
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
page. City/Town State Zip Code Date of Inspection °%'
t.3„4
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, / LUU
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
key the return Name of Inspector
Y
Cape Cod Septic Services
Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails'
❑ Needs Further Evaluation by the Local Approving Authority
� 5/28/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
G jy td V
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�MP, 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owners Name
information is Wakefield
required for every MA 01880 5/18/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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.
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):
4
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
oL\
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required for every MA 01880 5/18/2018
page. Cltyrrown 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):
Box is rotted and needs to be replaced. Garbage disposal also installed and in use with septic not
designed for its use. Disposal needs to be removed.
t
❑ 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
• d Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`M ,•'�t 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required for every MA 01880 5/18/2018
page. Cltyrrown 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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
• 0 ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name -
information is
required for every Wakefield MA 01880 5/18/2018
page. Cltyrrown 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-
1 0,000g pd.
❑ ® 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
G W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
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
❑ Z Were any of the system components pumped out in the previous two weeks?
❑
® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3=
330gpd
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M V•,r 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name -
information is
required for every Wakefield MA 01880 5/18/2018
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? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use?
® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)): 2016=74gpd
Detail 2017=269gpd
Sump pump? ❑ Yes ❑ No
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? ❑ '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
Vk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
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: No records
Was system pumped as.part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records; if any)
❑. Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
i
t5ins•M3
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owners Name
information is Wakefield
required for every MA 01880 5/18/2018
page. CItyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1998 Per BOH records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: 6"feet
Material of construction:
®concrete ❑ metal ❑.fiberglass ❑ polyethylene
El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500Gal
I
Sludge depth: 4-6"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e.
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
page. City/Town 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
Scum thickness 2-3"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers
6" below grade. Recommend service of tank.
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
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required for every MA 01880 5/18/2018
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
u W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M sa't 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
page. CltylTown 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 Oil
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.):
Walls of box are rotted. Box needs to be replaced. Cover 10" below grade.
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
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required for every MA 01880 5/18/2018
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number-:
® leaching chambers number: 5-Infiltrators
❑ leaching galleries number:
Teaching 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.):
5-Infiltrators with stone in.a Tx39'Trench. No standing effluent in chambers during inspection. No
evident staining. No sign of overloading or hydraulic failure.
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
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 'y 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required for every MA 01880 5/18/2018
page. Cltyrrown 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•3113 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 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is Wakefield
required.for every MA 01880 5/18/2018
page. Cltyrrown 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
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
u = Title 5 Official Inspection Form
a Subsurface Sewage Disposal System
m Form Not for Voluntary Assessments
� 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
page. City/Town 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:
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: 1998
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:
Test hole data per plan on file at BOH. MOre than 5'separation from bottom of SAS.
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
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 149 Sixth Ave. Hyannis, MA 02601
Property Address
Paula Harding. 3 Andrews Cir.
Owner Owner's Name
information is
required for every Wakefield MA 01880 5/18/2018
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-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
-JJutrL%-df-UN Page 1 of 2
TOWN OF BARNSTA13LE (V
LOCATION `UI YJ O/✓i±' SEWAGE# —
vII LAGE /�i. N 4�1yf8�f7i'T ASSESSOR'S MAP&LOTZ� -07
INSTALLER'S NAME&PHONE NO. f�'Oy��" %�S•gs��L� i
SEPTIC TANK CAPACITY /.Ibo4d
LEACHING FACILITY: (3' 'X3
(size) 79�
NO.OF BEDROOMS
BUILDER OR OWNER Ir
PERMITDATE: 6-05 Ig� COMPLIANCE DATE: -7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sfi Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) elm Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnishcd by
Iq _ l
3g �
t
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=245076&seq=1 5/15/2018
TOWN OF BARNSTABLE
LOCATION lI/? , 44X2`1 404'e SEWAGE # ='385
VILLAGE }j�4'��ll��D/'T _ ASSESSOR'S MAP & LOTZ—V57- 7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACTTY
ll
LEACHING FACILITY: (type)1_14 ,�' —, (size) '7 ax 39.�w"
NO.OF BEDROOMS 3
BUILDER OR OWNER //��
PERM TDATE: 6`"ZS —7� COMPLIANCE DATE: 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s f Feet
Private Water Supply Welland 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 Feet
within 300 feet of leaching facility) IdA
Furnished by
I -
0 _ a
Ir �
19
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� �.
w 7SF
o^
� ,„_
cO Certified Mail Fee.
Er
Extra Services&Fees(check box;add fee as appropriate) �
❑Return Receipt(hardcopy) $ �ya+°d'
0 Return Receipt(elect(pnlc) $ Postmark `
1-3 []Certified Mail Restricted Delivery $
C3 []Adult Signature Required $
Adult Signature Restricted Delivery
O Postage ta —r
Total Posge C}Qy
$ CALAUTTI, SALVATORE &-6 A
a Sent To 3 ANDREWS CIRCLE
C3 StieeiandAp; WAKEFIELD, MA 01880
Ciiy,�Stafe,Zll
:.r r r r rrr•r.
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
•A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this j•;
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(including the recipients retail associate.
signature)that is retained by the Postal Service- Restricted delivery service,which provides ^Ty
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent s
Important Reminders. Adult signature service;which requires the ram.
■You may purchase Certified Mail service with signee to be at least 21 years of age(not •1
First-Class Mail®,.First-Class Package Service®, available at retail). -r;
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age,
intemational mail. and provides delivery to the addressee specked j
■Insurance co'vemge Is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark If you would like a postmark on 7'
•For an additional fee,and with a proper this Certified Mail receipt,please present your -7
endorsement on the mailpiece,you may request Certified Mail Rem at a Post Office-for T,
the following services: postmarking.R you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion U
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply I~
You can request a hardcopy return receipt or an. appropriate postage,and deposit the mailpiece. rj
electronic version.Fora hardcopy return receipt, i
complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORTARr Save this receipt for your records.
Ps Form 3800,April 2o15(Reverse)PSN 753e-02-ooe-9o47
1
■ Complete items 1,2,and 3. A.
■ Print your name and address on the reverse XSigna ❑Agent
so that we can return the card to you: v�h ❑Addressee
• Attach this card to the back of the mailpiece, d b n, a C. Date of Delivery
or on the front if space permits. �I
D. Is delivery address different 44 item 1? ❑Yes
If YES,enter delivery addres elow: 0 No
ICALAUTTI, SALVATORE & OLGA
t 3 ANDREWS CIRCLE
WAKEFIELD, MA 01880
II I�11181 ICI IBI I II II II I I IIIII I II I I I III�I III 3. Service Type ❑Priority Mail Express®
❑Adult Signature ❑Registered Mal TM
Adult Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 1933 6123 1775 17 Certified Mail® elivery
❑Certified Mail Restricted Delivery etum Receipt for
❑Collect on Delivery Merchandise
❑Collector Delivery Restricted Delivery Signature ConfirmationTM
2. Article Number(transfer from service label)��,-. Collect-op,
❑Signature Confirmation
7 015 17 3 0 `0 11001 4 9:8 7 9 9 7 2 'ail Restricted Delivery Restricted Delivery
r PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
USPS TRACKING#
First-Class Mail
Postage&Fees Paid
lill it .
USPS'
Permit No.G-10
9590 .9402 All-VIt2� 1775 17 �
United States •Sender:Please print your name,address,and ZIP+4®in this box•
Postal Service
d Town of Barnstable
p;8 Health Division
! 200 Main Street'
Hyannis,MA 02601
I
I I I
I
.' fill �IEIi FIiII:i IFFS.tI}Fjili FTiiFi1{1` il FFF FtIFl�F1�i= Iii1
l 7 7,&/
No. { Fee -S��V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
ZippYication for Mgooal *pgtem Construction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ? Complete System ❑Individual Components
Location Address or Lot No. tJ® �l y�— a � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 9
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
A®r faG®1✓`J
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(,_�b
Other Type of Building 1i/?GeNo. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Ile gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /✓�®D Type of S.A.S. le.Ir
Description of Soil
r
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 in operation until a Certifi-
cate of Compliance has been issued by his Bo d of ealth. `
Signed Date 6 _2- Q6-
Application Approved by Date z. C
Application Disapproved for the flowing reasons
Permit No. Date Issued
-61
No. ._ � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: \//
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0[pprication for ligp/ogar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) L complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address andTel.No.
Assessor's Map/Parcel, /� L�/'/�O�rJ� oc//ewo.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
r;
Type of Building: ?
ti Dwelling No of Bedrooms J Lot Size is, sq'ft. Garbage Grinder(�r�
Other Type of Building ° &We e'iNo:�of Persons Showers( ) Cafeteria
Other Fixtures - ,t
Design Flow Ile gallons-per day. Calculated daily flow gallons.
Plan Date Numlier`of sheets- « Revision Date
Title
Size of Septic Tank Typp`4f :k.S.
l
Description of Soil L7�C
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 in operation until a Certifi-
cate of Compliance has been issued by his Bold of Health. Date d/�Z/�'
Signed
Application Approved by Date
Application Disapproved for the flowing reasons
3.
Permit No. - Date Issued
- .. --------------------------'--- — — ----
THE COMMONWEALTH OF MASSACHUSETTS Z 7a
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( kl<Upgraded( )
Abandoned( )by /LLD /'
at 7' all has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. N-3 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date �., 9 V Inspector
�{N. ----------------- ------ ! ®�b/ Fee �l�3
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
'Wigpogar *pgte Congtruction Permit
Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( )
System located at /
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: ell
-- Approved by
C7 39
00 ,
00
��IclP6ss.A .D 'g°�'-
04
� .lvprfaysal�p✓n f
IOIW97 Rey
NOTICE: This Form- Is To Be Used For the Repair Of Failed
Se c Systems Only
L
CERTIFICATION O =SKETCH AND APPLICATION FOR A ��
DISPOSAL WORKS:CONSTRUCTION PERMIT (WITHOUT ,k
ENGINEERED PLANS)
r
r ;
�ereby certify that the application for disposal worksX? r
�u
construction permit signed by me dated l?",Z concerning the
meets.all of the
property located at
oilowing criteria: rx
V) There are no wetlands located within :oo fee:of:he proposed leac,ing facility
There are no private weils within ::o Soot of:he_r000sed Septic syste^t
There s ao ;ncrerse in now and/or:aange :n-lse=r000sed
,,nere are no variances requested or:eeced. x:
if the proposed leaciung ac:ii[v wiil :e :oca[ec .vitnin =:� feet of Inv xe:lards. :he cet-.cr. of me
il :e :ccated :ess:nan :ounee:.
proposed leaching facility xi :e-t above
na c:mt r:1 :d;t�m.ec
groundwater mb.Veieuation. =_
Please complete the following: _
A)Top of Ground Elevation kaccording:o the following-
' Division G.I.S. napj
B)Observed Groundwater'able Elevation(according to Health Division well map i _
DATE:
SIGNED:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
Attach a sketch plan of du proposed;ystan-Also if the licensed ulstalla pasasa a cerpfud plot plan.
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