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HomeMy WebLinkAbout0012 SMITH STREET - Health 12 SMITH ST., HYANNIS A=28$-191 i I i I 1 ° i 4 0+!x s✓ x _ � a c�; �� v ��`� -_ \ ^\\ 6 t �. I' I1 �� �� I ,� o �� c\J � � Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is Hyannis ✓ Ma 02563 6-9-2021 required for every H y - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A.-General Information on the computer, 1 use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation � Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification 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 6-9-2021 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. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 z � Commonwealth of Massachusetts, u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form__.. . ._._.. - Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is Hyannis Ma 02563 6-9-2021 required for every y 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: The system.was in working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): El 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 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 12 Smith Street 0 . Property Address Frank McAdams& Nick Esposito Owner Owner's Name -formation is-equired for every Hyannis Ma 02563 6-9-2021 cage. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Iv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No - ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ • ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ Elthe 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 Title 5 Official Inspection Form T p Y a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 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) ❑ Z Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Z� ❑ 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): 330/GPD t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection D. System Information Description: L Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( y 9 (gP ))� . Detail: 2020-26,928gallons 2019-25,432gallons Sump pump? . ❑ Yes ® No Last date of occupancy: 1 week priorDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w ."V 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 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: Owner-last pumped 4 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection Form -- — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I ., 12 Smith Street Property Address Frank McAdams & Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 6-30-98 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'4" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1'4 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: 1500gallons Sludge depth: 4" l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form ........ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma _ 02563 6-9-2021 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 32 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 I Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA If pumps or alarms are not in working order, system is a conditional pass. _Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ Teaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 infiltrators ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 I Commonwealth of Massachusetts w/z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ....... 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name informed for every Hyannis is required H annis Ma 02563 6-9-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner. Owner's Name information is required for every y H annis Ma 02563 6-9-2021 page. City/Town 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 (D Vo B A c D 2 Driveway Al 0" -5 B A(-12f6" 82-38' C2-1 5A D3-191 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 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: No GW 5' below SAS 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: Town sign off 8-3-98 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: Information on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Frank McAdams& Nick Esposito Owner Owner's Name information is required for every Hyannis Ma 02563 6-9-2021 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 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G-L -it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. 20 / + DATE: I Fill in lease ` ,;�N f. APPLICANT'S YOUR NAME/S: =tif ? " ` ' I BUSINESS YOUR HOME AD RESS: r E7 TELEPHONE # Hom Tel ne Nu er ar E I N R :* 3 � E-MAIL: 5 � L v NAME OF CORPORATION;A .� NAME OF-NEW BUSINESS. ) f. ,WA, TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES ' NO nQ -l I ADDRESS OF BUSINESS 1 MAP/PARCEL NUMBER o�U (Assessing) . When starting a new business there are several things you must do in order to be in compliance with the rules and regulations-of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need; You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) t ake sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CC MMISSI ER'S OFF , This indivi al h e r� d f any) m7teq irements that pert to this type of business. MUST COMPLY WITH HOME OCCUPATION Authors Sig a ur ` RULES AND REGULATIONS. FAILURE TOIPQ . MMENT I L ' COMPLY MAY RESULT IN FINES. 1 ; 1 2. BOARD OF HEALTH This individual has be , i ormed oft e p�mit requi ents that pertain to this type of business. on ed Signature * M*-'COMPLYINITRALL' . COMMENTS: ' HAZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date: I I TOWN OF BARNSTABLE °�� TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF'-BUSINESS: PA 5 ' -t,) c BUSINESS LOCATION: 5-r tl INVENTOR MAILING ADDRESS: TOTAL AMdUNT: TELEPHONE NUMBER: / CONTACT PERSON: l EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: �QQ INFORMATION / RECOMMEN TIONS: Fire District: i Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED T Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids r 5 , . (dry cleaners) h Other cleaning solvents ` Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials A ,. � r r. �� •...wa.p:^^.'"..}i."q---!'+-.k�.-r1's`�."`*,�';i"'*tnZW1...,1� �rn . .M �'� ^�.�:. -... ,.,,�.,_., j,....."�.. .,.. -", - .. "'`.r.7h..� .`�+7t"'.'°•^A...1.�.w'"y.r1+-,ihy.n+ +4�"�l.-rr--•-vf..y�4 r '4.,.r..,. TOWN OF BARNSTABLE 2968 Ordinance or Regulation s WARNING NOTICE Name of Offender/Manager ( i � 0 Address of Offender ` �( ,, j / MV/MB Reg.#JlZs Village/State/Zips 1 A� 1, a % v , ... UK Business Name /P0j; on ��ll11720 Business Address. Signature .of,E,nfor c ,ng Officer Village/State/Zip Location of Offense :C ,� .� % ? ' Y/ 03 t r, ,. p... Y.y ea 1 Enforcing Dept,%Divis_ on Offense,.,.' Ao .' 1 , r � f -77 Facts o.D&wn Yn 11n 1)-3r CZ,611AI--()P 16 This will serve only as a warning. At this time no .legal action has been taken., It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts` and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. / ' ^- �^-ram._r^...rti..w..a•.'.....r^*..Ftti.. :w-.r•w..a_. •...5�.`.iz^,.rti,ss..+.^`.rrw^n�::.tMv��w`r. .. t - . __, \ l —fY�*...c^r'a.-.n3'f^q✓'�:R....c Yr"'1._'"`^.+5..,a�i''r•-a9tw..:.,'�;yP� r:ti'�+4r..,.r...r-r7 TOWN OF BARNSTABLE . BAk 2969 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager i ! �' ,t jj�il ``�r Address of Offender MV/MB Reg.# Village./State/Zip /{ Business Name , %Mrippi, one. "/��20 Business Address � f� :z CJ `r `1. i t :f Signature .of,'�Enforc ng Officer/' Village/State/Zip Location of ,offense r�J t /,t ,, �Y/1,1V_' 1--- , .. 9 Y r �� uz�' J.Enforcing Dept/Division ,l "Offense 0f' N «� 'a . cj-. O � f0AI "_- Facts 1 ,JC_ :. >!'f ! �` ./ '/lr +`"` 'N j t<+ ✓ 7' ' lf, � '�r� /y') This will serve only as a warn,2.ng. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are at to gain voluntary compliance. Subsequent violations will result in appropriate legal action by/the, Town. I , � TOWN OF BARNSTABLE BA 2000 Ordinance or Regulation WARNING NOTICE Name of Offender/Manage Address of Offender ram, , r t' MV/MB Reg.# 't�"t w.> , Village/State/Zip Business Name ` fam/ptri; on 20 ;, f Business Address Signature .of/Enforcing Officer • , Village/State/Zips Location of Offense J }" # t �± ! ,�, , I,, ' �I t< . Efnforj(cing* Dept/Division Offense E ' V �� ✓��� *'may R' y f '` '1 ! rrn tt Facts f�. t °`* s ., This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by/the Town. , / ' ;, �- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w �.µ °M 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. City/Town State Zip Code Date of Inspection IS 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, k� / use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 SI 13747 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 6-29-18 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. _ B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every H annis Ma 02563 6-29-2018 y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is H annis Ma 02563 6-29-2018 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): — 3 -Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD t5ins•3/13 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 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma , 02563 6-29-2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2016- 147,356gallons 2017- 166,056gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 18 months ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ . Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and -maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 6-30-98 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 4 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1'4" feet Material of construction: Z 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: 1500gallons Sludge depth: 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32' Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: NA 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-W13 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 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is Hyannis Ma 02563 6-29-2018 required for every y page. Citylrown 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.): F Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 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 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 infiltrators ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was full when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 page. City/Town 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 1 c/o B A C D. Driveway A1-50" B1-12,6" B2.38' 3 C2-15` D3-1 W t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 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: No GW 5' below SAS 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: Town sign off 8-3-98 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: Information on file with BOH. 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 12 Smith Street Property Address Sandra Walker Owner Owner's Name information is required for every Hyannis Ma 02563 6-29-2018 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 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LO) ATION Z � �� f"�e 5�` SEWAGE # V LAGE /7�/�f�/J/�5 ASSESSOR'S MAP& LOTS Z!k 11' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S-ovn Gsl LEACHING FACILITY: (type)�whr1 il a►d (size) 4 J 39,T ;4 NO.OF BEDROOMS 3 BUILDER PERMITDATE: Ja'l COMPLIANCE DATE: " Ll 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 f on site or within 200 feet of leaching facility) W/Y Feet .Edge of Wetland and Leaching Facility(If any wetlands_exisi Within 300 feet of leaching facility) 409 Feet Furnished by 3 7- �4 gal ww ��4a r 4 aAct D c 4 No. r, Fee computer: THE COMMONWEALTH OF MASSACHUSETTS Entered in com p Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplicatton for 30igpogal *pgtem Cow5truction Verna Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) M Complete System El Individual Components Location Address or Lot No. !Z v& Owne'r'ss Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ow ry Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(Ileo Other Type of Building —e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily.flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1,5r®D Type of S.A.S. Description of Soil _ _ y`�d G9� i11 ��/�✓� ._ --- l 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 b this B: d of 4Health. `�',/ Signed Date / 01ex Application Approved by - . Date Application Disapproved for the following reasons Permit No. /) ` Z 17 Date Issued .30 �� _Z $ 1 No. r, k _ti Fee } .w.Y,P�iyp4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Y- Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHUSETTS i yp Application for Mi!gpogar *pgtem Co'n0truction_permit - Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) F Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ` Assessor'sMap/Parcel /f✓�,�r �� wvls�` 5,owl Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/ a Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /gr0�. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ! ✓'Z', %/" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system s 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 b this Bo d of Health. Signed Date d/�1�X Application Approved by _ -Date GZ3014 Application Disapproved for the following reasons t (51 r Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site.,Sewage Disposal System Constructed ( )Repaired ( P)Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �'3r!? dated 6/,�v 9 F Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date <X ; I (�0 Inspector ----- -----._— ------ f�— / ——— � T} --- No. v ��f Fee J�/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1=igpogaf *pgtem Conztructiott permit Permission is hereby granted to Construct( )Repair( j/lllue pgrade( )Abandon( ) System located at 51l;6 ) r, 7" and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply p y with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this p it Y . Date: �' �� �! Approved b iiss•. 1019/97 fir. NOTICE: This Form Is To Be Used For the Repair Of FailediF. .Septic Systems Only.. l CERTIFICATION OF-SKETCH AND APPLICATION FOR , DISPOSAL WORKS:CONSTRUCTION PERMIT (WITHOUT PLANS) ENGINEERED Afi ;F herebv certify that the application for disposal works x rr construction permit signed by me dated �i �� e,,�r . concerning the property located at lZ1 U`^AIJ�J`�I �y����s mees.alI of the �'* ioilowing criteria: nere are no wetlands located within :oo tee:of-.he pr000sed le ing ,-aciiiry tv/7 here are no orivate weils within ::0 lee:of:he:rcoosed_ep[ic syste n ZTLre s no :ncrea_se in now andier_i:anee in -ise:rcosed he � . :nere are no variances reauestea or needed. Iw Ne �dr- *he ^Cact;+ Jr ,1e # , � ,;! �,P :cca[ed.ess:nan :uuiae. � . ._.._ ,;c• _ ..... ... .. - . - i�f�J��J�61 �sceltng fac:::a. a i. i". Please complete the following: accordin¢:o the Engineering Division G.LS. map j A)Top of Ground Elevation k _ �— B)Observed Groundwater Tabie Elevation(according to Health Division well mat)) k SIGNED: DATE: 0 C� Z , LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 41 ' plan of dte Proposed"M., .Also if the licensed installer posesses a certified plot plan, �� (Atrmch s slutcb WAR .� y r =rthti:PliA s"b' t "..�`" 'P y:J¢p (%3�'S���S�,� 't✓e���� � 4x{ t� C f SK� �--3rF 4!. k - - k •Jn., S T"r: �"S, - M '; Y+ - - �YS-" x3,�"✓�y� '. --sf-f { + ' -v �'i g,�-'+�, >i<'rn^C ``'.r, ��tF +4,.3 � :, ';• :`a ..xrS+-`Yr* "tt C;,c.'Y,'. ,, w.. r '."t,�. - s x"`�' y";�`.;'.r� k + •�7 }�.v"�''., "+ .�'?�> < -``tom z `'�" .r.':;r �."`}"'.F'a r1 a .rt 4 r�r,,.• ��vs.��� '_ ,.. ,G ,'�. �'-�c.,�:� � ..���*� .F� .,�,�>s�, r`z<a�,�' - �'���.a Z'si�.���3���h'T .t�-�" i i TOWN OF BARNSTABLE LOCATION 12- ��l'' f"Gj 5 j`" SEWAGE VILLAGE /fJ�Q'/�i�/�9 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /s`00 GsL LEACHING FACILITY: (type),T 141,404 r(� (size) 9 �39,s.A I � NO.OF BEDROOMS 3 BUILDER OR 60WNE tyrl�� PERMITDATE: Ja`l COMPLIANCE DATE: Separation Distance Between the: - Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet 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 Furnished by 00 3$ Ga /ICY 3 �w v �� r Town of Barnstable Regulatory Services v IIARi`(ST'AHLE4 MASS ,� Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 James and Sandra Lee Walker January 29, 2007 112 Wixon Pond Rd. Mahapoc,NY 10544 NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: On January 29, 2007, Health Inspector Donald Desmarais, R.S. investigated a complaint regarding Trash and cars driving over the buildings septic tank atr12 Smith St. Hyannis. The following violations of 310 CMR 15.00, the State Environmental Code were observed: 310 CMR 15.226(3): Septic tank is a H10 loading and vehicles are driving over it. The tank must be H2O loading. You are directed to either install an H2O septic tank or block passage of vehicles over the current H10 tank. This is a potentially hazardous situation and you must correct this situation WITHIN 30 days. 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. Non-compliance will result in the issuance of a non-criminal ticket citation of $100. Each day's failure to comply with an order shall constitute a separate violation. (:jER O ER OF THE BOARD OF HEALTH Donald Desmarais RS Health Inspector Town of Barnstable I QAOrder letters\Septic\339 Pitchers Way.doc NAMEOF E /�. W&MBAR 66552 TOWN OF ADD 0 F NDER` \) BARNSTABLE CIT A C0 1t �ftMl /kolm ✓ l s 1D pf IN[ MVIMB REGISTRATION NUMBER 06PEN E © . a \IAtlx. 8. O �Eo M►+►`e w / > TIME AND DAT�F V OGA`nON L ASI�N OF V10J,AT 0 f,'' W NOTICE OF '1 /rPp)O / 20 II ��3 o IfAf a 19RE F NFORCING PERSOV, EN 0 fr E 3. �/ B UW VIOLATION w OF TOWN 1 HEREBY ACKNOWLIEGE RECEIPT OF CITATION X a ORDINANCE Unable to obtain signature of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS S p w Date mailed w OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w rn REGULATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to.pay any fine determined at the hearing to be due criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature q I TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out ' _Owner S�t.�-o _Aa LLG Tenant &A0 Alm (/�-�,r1 � � Address N ST Address 12, -SA4 r f I �( Compliance Remarks or Regulation# Yes INO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities S a IDI:-11ra;�—W, T-;A-SeiM f 10. Curtailment of Service 11. Space and Use - 12. Exits /cLT j p� l 2ccj 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of'Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Allow (max) Number of Persons Allowed (max) � Person(s) Interviewedr1/y 1 Inspector If Public Building such as Store or Hotel/Motel specify here