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Home My WebLink About0201 SIXTH AVENUE (HYANNIS) - Health 201 SIXTH AVENUE Hyannis A= 245 - 083 No.ff.—A .......... THE COMMONWEALTH OF MASSACHUSETTS r BOARD /®� F HEALTH ( ..................OF........ �f ..............._..... - Appliratiou for Dispaiial Works Toustrurtiou Prratit Application is hereby made for a Permit to Construct ( ) or Repair ()—in—Individual Sewage Disposal System at: `� .... L*t ...-Addrss orNo wwner Address......... ..._ � e -- ............................. .............................................. -�-•--•--c•.......a.-.-•y•••/•..l....l.... ......c....••- .-.C --• •---•- • •........--••------•--...--.---•- .^---- fi --•--......-i .07Rp�../. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......./57 .••_•-_..-•---•••-•-__-___•-Expansion Attic (h� Garbage Grinder (4/17 Other—T e of Building No, of persons............................ Showers a YP g -------------•-------------- P (----)..— Cafeteria-(- ) QOther fixtures ...-----•------------------------•..._...-------•------••••••••••••------••--.._............................-• -•-•- W Design Flow............................................gallons per person per day. Total daily flow.............------- ------- WSeptic Tank—Liquid capacity,/_, gallons length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.......fir._.-...... Total Length...S!G........... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ') Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2....:...........minutes per inch Depth of Test Pit.................... Depth to ground water...........;............ C4 .......................................................4..................................................................................................... 0 Description of Soil....-.......... --••-•---------------------------------------------------------------------------------------------------- x U -••-•••-••••••••••-•--•••••-•-•------•----•••--••••-••-•-••••••--••••••-•-•---•-•-•-••-••-•-•-----•--••••--••---•---•••••-•-•-•••••••----•-•••.....-•--•••-•••-•.................•-••---••••--•--------- W VNature of Repairs or Alterations—Answer when applicable.--_.___ ___ ___ ________ ___e_---------- .•-----.-----•--. ••---------------------------------------•-------•-------•------••--------------------•---•...--••--------...------------------------------------------- ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI11, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board o he Signed Application Approved BY g...... ate Application Disapproved for the following reason ................................................................................................................. -••--••---------------•••-••--••------••-•••-•-•-......•-•-...•---•••-••-•-•-••--••-•-- --- Date Permit No-ay `' .. Issued- Date No. ...... ...... . Fin;.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ....................O F....................................... Appliration for Disposal Works Tonstrurtion ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............:.._................................................................................ .......-•-••-------......_............------------.............---•-•-------•----.....--------.•-- Location-Address or Lot No. .................................................................................................. ...................................... Owner Address W Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-_•........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � YP g --------------•-----....---- P ( ) — Cafeteria ( ) dOther fixtures -----------------•-•--..._...__.....---........_.....----...••----......_............__.._._..--••---•••-•---•--••-••-----------•--------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No................T___. Width___.. ._.__.____._.. Total Length____................ Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W -•-•--•...--•----------•--••------------•--•--•-------•--•-••-----•-------------•••-..........---••-......................................................... 0 Description of Soil....................-................................................................................................................................................... U •----•-•----•----•----------••-•-----••---•---•--••----------•---•---------••---•--•----•-...........•----•--•••------••-----••------•------------•---•-----------•-------------------------••----.... W x ••---•----------------------------------•----••••--••----•----••----------------•---••-••--------•-•----•---------••-•---••------•-••------------------•-----•-•---------•-••-----------------•-••------ U Nature of Repairs or Alterations T Answer when applicable............................................................................................... -•------•-------------------•--------------•----------------------------........------..........--------------••------------...---------••--------------•-••--------•-•=_..._....---•--•-•-•--•-••••••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.......... --------------- -------- •-- ----- ---- 1 D e Application Approved By ...... ! i ....___ �'-------- --•-- ----------------- - - --- ate Application Disapproved for the following reason -- -.....................:-.................................................................................... ...........................................................................----•---....-•••------•--------•-----------•-----------...------•-••------ ----- ........................................ Date Permit No..4 .. .-- .- --------•-------. Issued__,,�_� - Date THE COMMONWEALTH OF MASSACHUSETTS B ARD OF HE LT V� .. ....OF... . �yv e � .,�. .`y!'............�..................................... :. C9rdifirate of TompliFattrr v P( AD� TH I ERTIFY That the nViiidual Sewage Disposal System constructed ( ) or Repair/" 4, }\by------- -- •. l i ,� -----------------------------•--••--------------• L_... !^ Instavd I e r.: ...._ has been installed in accordance with the provisions of !�' 5 of �ht Sanitary Cody a d cr•�H/i�THE ' the a lication for Dis osal Works onstruction Permit No._. _ __ ..: ��.. dated__..._ _ � PP P G ••------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.......................................-•--------- ... THE COMMONWEALTH OF MASSACHUSETTS OARD O HE LT � LZ-, /-7/ ' �'- Q >.. . . . O F... ... .: .11� .. No FEE-.. %nn amit Permission i d_..� .... --------------------------------- -------------------------------------- to Cons ar e ) I dividual e rag Di t at No.- A-Street � -as shown on the ap lication for Disposal Works Constructi rmit NO.',...... __ gated: g G?� -- -- •---•---------•-- ... ........................ r DATE_--.-•-• 1_ .. -_ .-- • Boa of Health ----••......•--•--.--•-.---.--•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No. ( Fee - b� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitafion for Vopo8al 6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z o 1 S i to-t k av aiYod,hiS Owner's Name,Address,and Tel.No. 1(a LW4 �ee A��l / 5 tharw M� Assessor's Map/Parcel ,Z Li r 01% Installer's Name,Address,and Tel.No. Designer's Narne,Address,and Tel.No. Vat to. s3 cow..- (mot Type of Building:' Dwelling No.of Bedrooms ►J Lot Size O sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided AM— gpd Plan Date 3 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) Q,v v t,w lv L J— i.✓a i k 2,e.ew 4"A 12 6 1b SI2_S, 76 U14-41 Date last inspected: Ff— 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 o H Si Date Application Approved by Date ft Application Disapproved by Date for the following reasons Permit No. ablcl-D5b Date Issued A:/ No. (` — Fee 1000 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ApplitatIon for Misposal 6pstem Construction Permit .Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or`Lot No. Z p 45 ,� pkv N��ah.� S Owner's Name,Address,and Tel.No. Assessor's Map/Parcel IY 1- p 5 JcA+ /►� Installer's Name,Address,and Tel.No. Designer's N e,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) -• , Other r Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided��) gpd Plan Date Iq— 19 Number of sheets Revision Date Title / Size of Septic Tank 1 1[�t7 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) p ,p W— in (.s—e--)" _2 n t24 ' Y►a v D rr -'7 r-, t Ste® T'Y_ L t Date last inspected: {�- 3 -L ovpl Agreement: i 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 He Signed / Date -2, Icr Application Approved by Date ? Application Disapproved by Date i for the following reasons Permit No. Date Issued tic, --------------------------------------- ----------------------------------------✓--/----------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS U BARNSTABLE,MASSACHUSETTS Certificate of Compliance "fHIf S TO C RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired W) Upgraded( ) Abandoned( )by /`'i �� y at 7�p I �i i s[i� 1 l _. ,�.) has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, q dated 7// ynj q Installer U12o, Designer #bedrooms n j Approved design flo A and The issu of this permit shall not be construe as a guarantee that the system Itn�ti'o I as design/-. Date 2 �� Inspector ---- - - -- ---- -- - -- - -- =.r- _-------- t - =.....�... - �:'.,........., .:^ y ,�_.-<_ ,.�-,,.. -.-. . _.,. .' .�- +v+.-.may No 00(9— 0% Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at. 2 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 permit. Date �/ /��7n�q Approved by p � o E' WI .. • '� Q.^ rl-- sA 43(117 Ce rtified Mail Fee Extra Services&.Fees(check box,add tee prep..) ❑RetumReceipt(hanicop» O ❑Return Receipt(electronlc) $ stmark 1-3 ❑Certified Mail Restricted Delivery $ $^ -Here C3 []Adult Signature Required $ w� ❑Adult Signature Restricted Delivery$ O Postage m Total Postage and Fees $ EISENTHAL, SHERMAN TR � Sent To 16 MAPLE AVENUE r CC3 SiieefandAV-ffcc.,oipdeoxN SHARON,MA02067 -' :.. 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 verificatipn•o.delivegof attempted return receipt for no additional fee,present this delivery rj USPS®-postmarked Certified Mail receipt to the •A record•of delivery(including the recipien retail associate. signat6 3,,t M is retained by the Postal Servlc Restricted delivery service,which provides for AsWr Gfied period:. delivery to the addressee specified by name,or j, , to the addressee's authorized agent -e Important Reminders: �" ', Adult signature service,which requires the■Yo may purchase Certified Mail service with signee to be at least 21 years of age(not Z F -`Class Mail",First-Class Package Service®, available at retail). o Parity Mail®service: ` U ,. Adult signature restricted delivery service,which •C r}tli�ed Mail service is notavailable for requires the signee to be at least 21 years of age, intemattonal mail. and provides delivery to the addressee specified:7 ■InsuMce coverage Is notavailabl}.e for.purchaje by name,or to the addressee's authorized agent•3 with Ceifie.Mail service.However,the purchase (not available at retail). of CertifieAbser6ice does not change,. •To ensure that your Certified Mail receipt is insurance coverage"automatically ihciii ed' I - accepted as legal proof of mailing,it should bear a" certain Priority Mail items.: x,.. USPS postmark.If you would like a postmark on F" ■For an additional fee,and with a proper. _.this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for F= the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion 1 of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply F. You can request a hardcopy return receipt or an- appropriate postage,and deposit the mailpiece. tiJ electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTANT.Save this receipt for your records. PS Form 3800,April 2016(Reverse)PSN 7530-02-000-9047 COMPLETEt SENDER: • ON ON . a vi . �. ■ Complete items�l,2,and 3. p Agent ■ Print your name.and address on the reverse so that we can return the card to you.. ❑Addressee ■ Attach this card to the back of the mailpiece, 0.,Rive by(Printed Dame) C.pate of Cplivery or on the front if space permits. ," D. Is delivery address different from item 1? ETYe { If YES,enter delivery address below: ❑No A F EISENTHA. ,-SHERMAN TR _ 16 MAPLE AVENUE j SHARON MA 02067 IIIIIIIII IIII III I III I III I II i I I II III III I II II III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaiITM I Adult Signature Restricted Delivery ❑Re ggistered Mail ResVicted Certified Mail® �IDellvery 9590 9402 3630 7305 4652 86 Certified Mail Restricted Delivery syReturn Receipt for ❑Collect on Delivery \Merchandise 2._Adicle_Number(rran_efas frnm_c n r-i,en ., n__CHI -r-.,.,;Delivery Restricted Delivery Signature Confirmation T^" F l.1 ❑Signature Confirmation 7015 17 3 0 ;D D:01 ;4 9 8 7 ,9 5 Ea 9 ul Restricted Delivery Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACKING# First=Class'"a"Postage&Fees Paid LISPS Permit No.G-10 9590 9402 3630 7305 4652 86 i United States •Sender:Please print your name,address,and ZIP+4®in this box Postal.Service es ; Town of fiamstable i Health Division 2.00 Main Street I Hyannis,MA 02601 I I II 111 1 i i t 1# H1t 1H, li I it r THE Town of Barnstable Barnstable Inspectional Services v BAfnAB , * p 1 1 MASS. Public Health Division 039. �0 m a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9569 March 8, 2019 EISENTHAL, SHERMAN TR 16 MAPLE AVENUE SHARON, MA 02067 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 201 Sixth Avenue, Hyannis,MA was inspected on 02/15/2019 by James D. Sears, 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: • The distribution box and 1110 septic tank are located under the driveway. These components must be upgraded to H2O or the driveway needs to be relocated. 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. PE4asMcKean, OF T E BOARD OF HEALTH Th R.S., 0 Agent of the Board of Health \SEPTIC\Title V Inspection Report Letters Mailin \Conditional) Passes Letters\201 Sixth Avenue H annis.doc Q p p g Y Y Town of Barnstable � 3ARN8TABLE, , �, ' Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ 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 water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: yam. d-6Q rr\l J- Q Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Sixth Ave ,;; v� Property Address *� y_.s. Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 r page. Cityfrown State Zip Code Date of lnspedioh 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. �auuullllnnr�7 Im octant:When filling out forms A. Inspector Information �( - 1�(ooZ(o ,,��;`• �,,,, on the computer, oa sG use only the tab James D.Sears = JAMES key to move your Name of Inspector =o' SEARS cursor-do not Ca wide Enterprises use the returnCompany Name ` key. 153 Commercial StreetSRIN SPEC4\o��`\ Company Address lunuul Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2-25-19 In Actors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/28/2018 Title 5 official Inspection Form:Subsurfaoe Sewage DiVosal System•Page 1 of 18 abed xeJ dH SSZZ 660Z 8Z qaJ Commonwealth of Massachusetts �- Title 5 official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. City/Tom State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: Conn pass H-10 Tank-D Box. The system is a 1000 Gal. Tank D Box and three chamber's 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): t5lnsp.doc rev,7120018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 2 of 1a Z a5ed Xed dH 55:ZZ 61.0Z K qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name Information is required for every Hyannis MA 02601 2-15-19 page. cltyrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Heath): ❑ 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): Need to replace D Box. H-10 Tank under parking area. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 15insp.doc•rev.7126/2018 Title 5 Dffiraal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 £ abed xeJ dH 99:ZZ 6 ME K 9ad i Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and.the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'*. Method used to determine distance: ••This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tfiinsp.doc-rev.7,26f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 t7 a5ed xe:1 dH 99:E 660Z 8Z 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form t- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information Is required for every Hyannis MA 02601 2-15-19 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in obi is less than 6"below invert or available volume is less than 1/a day flow A Z4 014/414 ❑ ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less.than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.j ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA, Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area —IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.726M18 Title 8 Official Inspection Form Subsurface Sewage Disposal System-Page 5 or 18 5 a5ed xeJ dH 55ZZ 6 60Z 8Z 9aJ I Commonwealth of Massachusetts r : Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments U 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is Hyannis MA 02601 2-15-19 required for every ,, page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all Inspections: Yes 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components: excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction; dimensions, depth of liquid,depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t5insp.doc•rev.712612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 1a 9 a5ed xej dH 99:ZZ 61.0E K 9ad f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is requlrrad for every Hyannis MA 02601 2-15-19 page. City/Town State Zip Code Date of Inspection D. System Information 1, Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 4 DESIGN flow based on 31C CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: 1000 Gal.Tank D Box and Three Chamber's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2017-49,371 Gals g ( y 9 (9t�))' 201B-59,096Ga1s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NADate tbinsp.doc-rev.7/2642018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 abed xed dH 99:Z2 660Z 8Z gad Commonwealth of Massachusetts Title 5 Official Inspection Form r. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page, Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercialtindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc,): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ®, No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc-rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 9 a6ed XeJ dH LSZZ 660Z 8Z Sad `y Commonwealth of Massachusetts Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owners Name information is Hyannis MA 02601 2-15-19 required for every page. CityrrDwn State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: teat Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.4oc-rev.7126/2018 Title 5Ofticia Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 6 a5ed xed dH LS ZZ 6 60Z 8Z 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form ) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0_ 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 paw, City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 23"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 3„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 0 8 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape -Sludge Judge 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 at working level. Tank at 23"below grade. Inlet cover steel at grade w/outlet cover at 1'. In and outlet tee's. No sign of leakage or overloading. Tank is H-10 under Black top parking area. Need to replace tank w1H-20 Tank or remove parking area over tank, f t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 10 of 4 o l, a5ed xed dH LWE 6 60Z 8Z qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owners Name information is required fur every Hyannis MA 02601 2-15-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 151nsp.doc rev.7262018 Title 5 omeisl Inspection Form:subsurface sewage Disposal system-page 11 of 1a 6 abed xed dH LSZZ 61.0Z 8Z 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Sixth Ave 199; Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. City/Town State Zip Code Date of Inspeclion D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and Float switches, etc,): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): D Box is 30"x30"-34" below grade w/cover at 1'. One line out.Wall's are gone on box. Need to replace D Box. Note: D Box in Black top_parking area. Need to install H-20 Box. t5insp.doc•rev.7.2612018 Title 5 Official inspeoson Form:Subsurface Sewage Disposal System•Page 12 of 18 el, abed xed dH 89:ZZ 6 60Z 8Z q8d I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Sixth Ave U Property Address Sherman Eisenthal Owner Owners Name Information is required for every -Hyannis annis MA 02601 2-15-19 page, CitylTown State Zip Code Date of Inspection D. System information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length; ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7126/2018 Tide 5 Or6del Inspadon Form:Subsurface Sewage Disposal System•Page 13 of 18 El, abed xed dH 89ZZ 6l•OZ K gad Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 11. Soil Absorption System(SAS)(cost.) Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching is three flows under black top parking area. Chambers are 38"below grade. Chambers are clean and dry w/clean wall's and stone No sign of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc-rev.7128l2018 Title 5 of al Inspedlon Form:Subsurface Sewage Disposal System-Page 14 of 18 t7I, a5ed xej dH 85Z2 61.0Z 8Z 9aJ Commonwealth of Massachusetts _ Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �vrw 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locale on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)-. t5insp.doc•rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Olspoeal system•Page 15 of 16 5 6 a5ed xed dH 99:ZZ 6 XZ 8Z 9ad I _ Commonwealth of Massachusetts RTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is required for every Hyannis MA 02601 2-15-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or 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 1—R o N-r 7,a Nk 1AI-40 To /= Mo Q0 To i/ �� 2 ,gip ek .-fop t5insp.doc-my.7/26/2018 Title 5Official Inspection Form:Subsurface Sewaga Disposal System-Page 18 Of 18 g 6 abed xed dH 89:Z2 6 1,0E 8Z qad f Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information Is required for every Hyannis MA 02601 2-15-19 per. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 8 Estimated depth to 40 ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked 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: Hand Auger 8'to G.W,. Bottom of flow's at 5'below grade. Bottom of flow's at 3'above G.W. and 2'above ADJ High G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7l28/2018 Title 5 Official InspedNon Form:SubsuAace Sewage Disposed System-Page 17 o118 a6ed xeJ dH 85ZZ 6Me 8Z 9aJ <C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 201 Sixth Ave Property Address Sherman Eisenthal Owner Owner's Name information is Hyannis MA 02601 2-15-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B.Certification: Signed & Dated and 1, 2, 3,or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 45insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 a5ed xe 8 6 d dH 69:ZZ 6 602 82 9ad