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Home My WebLink About0041 SMITH STREET - Health Al Smith Street Hyannis F A = 288, 014, G µ 4„1}� Ilia 'I a 4 F n. a t A: �1 �k d I 0 91 o Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith —3 Owner Owner's Name information is H annis ort ✓ Ma 02647 12-8-15 required for every y p �~ page. CityTrown State Zip Code Date of Inspection r>r a-� 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 GJ on the computer, 1 use only the tab 1. Inspector: key to move your p cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation �I Company Name 14 Teabegy Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 12-8-15 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. /-Oj �S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pel17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hy p annis ort Ma 02647 12-8-15 State Zip Code Date of Inspection page. City/Town p p 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: f 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. El Y ❑ N ❑ ND�(Explain below): t5ins•3/13 Title 5.Officjall Inspection Form:Subsurface Sewage Disposal System•Page 2 of 11 f Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hy p annis ort Ma 02647 12-8-15 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page.e. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health.(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day-flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well iconsidered If you have answered yes to any question in Section E the system s a 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage see below 9 ( Y 9 (gpd))� Detail: 2013-81,750gallons 2014-53,250gallons Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information owner-last pump unknown 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 M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 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: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet 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.): Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 8" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 5„ Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts 4OF Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G1,y, SVBy`w 41 Smith Street Property Address Gary Smith Owner Owner's Name information is p required for every y H annis ort Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade:. Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No, Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection t D. System Information (cont.) Box if present must be opened) locate on site plan): Distributiono es t (. p P ) ( P ) Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leachingchambers number: 3 flow diffs (31'x12'x1') ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Leaching shows no sign of back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 { l Commonwealth of Massachusetts o- Title 5 Official Inspection Form o. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every HY P annis ort Ma 02647 12-8-15 page. Citylrown 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 El drawing attached separately A 6 O O O O O t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System--Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Smith Street Property Address Gary Smith Owner Owner's Name information is H is ort Ma 02647 12-8-15 required for every yannp 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: 5.09' 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: 4-25-05 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: Plan 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM. yv 41 Smith Street Property Address Gary Smith Owner Owner's Name information is required for every Hyannisport Ma 02647 12-8-15 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 Z 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 TOWN OF BARNSTABLE �LOCA,77,ON III SL- SEWAGE # c)0'65 17g VILLAGE ASSESSOR'S MAP & LOTaRW-I'f INSTALLER'S NAME&PHONE NO. GvPK ,.' ^ _5eef7 , S2fr77S SEPTIC TANK CAPACITY /006 C-1-ROAR 777 r.. LEACHING FACILITY: (type).3x 1�C low j( (jruscr-r (size) Pyo,<l NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �� ®S' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist i within 300 feet of leaching facility) Feet Furnished by ?648 64f t t � A r P P Q , Uzi -_ Al t � 4 ' wl 1 1 4 $ 8 Utl — t D (&-4 li.- y�2J ►?, Fee 00 ' " No. ' THE COMMO&E;WTH OF MASSACHUSETTS Entered in compute Yea PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for 3010paal Spotem Con!aruttton Permit Application for a Permit to Construct( . )Repair( X)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7 8 1 —7 4 0—2 5 2 6 41 Smith St, Hyannisport Michael & Sacha Negron Assessor'sMap/Parcel 288/14 8 Green St Ct, Hingham, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(10) 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) We will install a new Title 5 leach system to plans of Eco—Tech, #ETE-1978 revise — — 5 . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Ba2r Health. C --p Signed d Date5,-- Signed Application Approved by Date Application Disapproved for Ne following reasons Permit No. 2 Gus=l-7 ff Date Issued ------------------------------------- _�/'�_. .y/i. .•..T.' y-..-, .r .. .... ..;yf ,� :t X.,,.� .-...yw. �+A1... w � '��,r _. t.- .�ti--.,J�^°.a'.�..-.. ^,..'Tsow..r—r..►"-.�,r,.r� R .. .:.-„�•—wv.��ti.,—.,+-r^�� No. bo (t!1°U � ' �� Fee 3„ �,� �'�✓ THE'"COMMON�IV'E'6H OF MASSACHUSETTS Y Entered in compute Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 0pplicatiowfor 3igpool 6pgtem Construction Permit °C Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. O ner' Nam Ad res d el.No 7 6 ` 41 Smith St, Hyanni,.sport Iic$zae aCha Negron . Assessor'sMap/Parcel 288/14 8 Green. 'St Ct, Hingham, MA Installer's Name,Address,and Tel.No. 5- Designer's Name,Address and Tel.No. — 4. Wm E Robinson Sr Septic Eco-Tech PO Box 1089r Centerville 43 Triangle Cir, Sandwich Type of Building: 3 ' �10 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 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 Type of S.A.S. Description of Soil Nature of Repa r lte ns( swer he applicable) We will install a new Title 5 l �nA s s em`�io p`.atis or — ' , #ETE-1978 r 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 E vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issto b, t ' oar of Health.f� j 7„ p Signed y1/h '-� Date! v� Application Approved by Date. v Application Disapproved for the following reasons F Permit No. 02 G yS r l Date Issued THE COMMONWEALTH OF MASSACHUSETTS Negron BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that xhe On-site Sew e DDisposal Syste Constructed ( ) Repaired (X )Upgraded Abandot}jq( Sr�iiyCi ( ) wm h xobinson Sr peptic Service r - at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit n Ir dated Installer �` � Designer The issuance of this permit shall of be-corlst•rued as a guarantee that the system w• 1 unction as designed. Date Inspector No. aUus '�70 Fee Negron THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1wi.5pogal *pgteXn Construction Permit Permission is hereby g a tte�.igftp,strgctt e �Repa �a titJJ gjr d� t )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. /1 Provided:Construction Gmust be completed within three years of the date of this-permit�l u Date:_ Approved by v a r , Town of Barnstable -I.IHEram, Regulatory Services do Thomas F.Geiler,Director • antt�m Public Health Division 163.9 �0 Fos Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 ` Office: 508-862-4644 _ Fax: 508-790-6304 Installer& Designer Certification Form Date: ✓ `�(j Designer: Eco—Tech Installer• Wm E Robinson Sr Septic L. Address: 43 Triangle Circle Address: PO Box 1089 Sandwich Centerville On Wm E Robinson Sr Sepbwissued apermit to.install a (date) (installer) STFrvice Septic system at 41 Smith St, Hyannisport based on.a design drawn by (address) Eco-Tech dated 04-19-05 (designer) I certify that the septic system referenced above was installed substantially;:accordingAo the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. GP+� o D:' er's Signa e) c.•�. F;^k}oet. y vc> c ;3 0 y %9Cowl Q �NfT.AP� (Designer's Signature) (Affix Designer's Stamp Here) r 3 PLEASE RETURN TO BARNSTAME PUBLIC HEALTH DIVISION.. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. fi THANK YOU. Q:Health/Septic/Designer Certification Form COMMONWEALTH OF MASSACHUSETTS sa Z b EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION APkv `L$� FArLED INSPECTION 'ARCM„ DT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 41 Smith Street RE iEA�/�� annisnort Owner's Name: ga(-h;; NNagron UE C 1 Owner's Address:�g�og 1 6 2004. Date of Inspection:- s —) i V-/ TAW N op EALTH R%7-ABL KEPT. E Name of Inspector:(please print) W i 1 1 i am E_-• Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville. MA Telephone Number:- (508) 775-8776 CERTIFICATION STATEMENT 1 certify that 1 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.1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5`(310 CMR 15.000). The system: Passes Co ditionally Passes eeds Further Evaluation by the Local Approving Authority Fails Inspector's Signature: t V ' Date: _A2--/ 3•—b �) 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 approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: 41 Smith Street Hyannispor Owner: Saeha Negron Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: e I have not found any information which indicates that any of the failure criteria described in 310 CMPI 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments• I B. System Conditionally Passes:I One more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfrltration 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 l r at the tank is less than 20 yea old is available. ND explain+ O �ervation of sewage backup or break out or high static water level in the distribution box due to-broken or _ obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approv�of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obswucted pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rt movcd ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 Smith Street Hyannisport Owner: Sacha .Negron Date of Inspection: ? _ C Fu her 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. Sys`tm will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the systelt is not functioning in a manner which will protect public health,safety,and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is filrnctioning 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. JThe 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 y p and the SAS is less than 100 feet but 50 feet or more front a pr'(ate water supply well" Method used to determine distance 'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and - th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fai ure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other,: 1 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATION(continued) Property Add ress: 41 Smith Street Hyannisport Owner: Sacha Negron Date of Inspection:/-;L-� D. System Failure Criteria applicable to all systems: Yo must indicate'). res"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 /L v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �G Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 'S Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow D Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number , �,` of times pumped LO Any portion of the SAS,cesspool or privy is below high ground water elevation. dZO Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface water supply. �La Any portion of a cesspool or privy is within a Zone 1 of a public well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] %1(YestNo)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 conside ed a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indic to either"yes"or"no"to each of the following: (The following c iteria apply to large systems in addition to the criteria above) yes no _ the syste is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of I public water supply well If you have answered''yes"to any question in Section E the system is considered a sigri ftcant threat,or answered "yes"in Section D abo'`ve the large system has fatted.The uAmcr or operator of wry large system considered a significant threat undo 'Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o%% er should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Smith Street Hvannisport Owner: sac--ha Neuron Date of Inspection: Check if the following have been done.You must indicate`)es"or"no"as to each of the following: Yes o _ 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? `s Has the system received normal flows in the previous two week period? C) Have large volumes of water been introduced to the system recently or as part of this inspection T. 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? zJ� Was the site inspected for signs of break out? S Were all system components,excluding the SAS,located on site? t Were the septic tankmanholes 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? a Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: .Yes no _k2 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. i�s unacceptable)13 10 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 Smith Street Hyannisport Owner: Sacha Neuron Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):.?96 Number of current residents: — Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):Ae) [if yes separate inspection required) Laundry system inspected(yes or no):/'LC) Seasonal use:(yes or no)2l. 0 Water meter readings,if available(last 2 years usage(gpd)): 2004 — 42, 000 Sump pump(yes or no): 2003 — 39, 750 Last date of occupancy: ;t 3-6�l COMMERCIA NDUSTRIAL Type of establis ent: Design flow(bas d on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap preselnt(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary wste discharged to the Title 5 system(yes or no):_ Water meter re dings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A✓ A Was system pumped as part of the inspection(yes or no): z>z,) If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPF�F SYSTEM _✓✓Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —_Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: lYC1, .6) Were sewage odors detected when arriving at the site(yes or no):/L 6 Page 7 of I I OFFICIAL INSPECTION FOI01—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA-1 PART C SYSTEM INFORMATION(continued) Property Address: 41 Smith Street Hyannispor Owner: Sacha Negron Dole of Inspccllon: BUILDING Sfs1VER(locate on site plan) Depth below g�radc: Materials of construction:_cast iron _40 PVC_other(explain): Distance Gon/private neater supply well or suction lute: Comments(on condition of jubils,venting,evidence of leakage,e1c.): SEPTIC TANK: locate`( on site plan) Depth below grade: ) % Material of construction: oncrele metal fiberglass�,olyet]nylene _othcr(explain) If tank is metal list age:+ Is age confinned•by a Cenificate of Compliance(yes or nq):_(attach a copy of Dimeccrli C io I d I n Dimensions: Sludge depth: Distance Gom top of sludge to bottom of Duffel tee or baffle: Scum thickness: 3�- 11 b � Distance from lop of scum to top of outlet Ice or baffle: g J t Distance [join bottom of sewn to bonom of outlet tee or baffle: i I low were dimensions determined; Comments(on pumping recommendations, inlet and outlet ice or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GIIEASE TRAP:_(locate on si plan) — Depth below grade:— Material of construction:--co Crete metal fiberglass_polyediy1cne`other (explain): — — Dimensions: Scum thickness: Distance from top of scut to top of outlet Ice or baffle: Distance Gom bottom o scum to boo Dill of outlet Ice or baffle: Date of last pumping: Conunents(on pump��'g reconiniendatiuns,inlet and outlet ice or baffle condition,structural integrity,liquid levels as iclaled to outlet innvert,evidence of leakage,etc.): page 8 of I I , OFFICIAL INSPECTION FORM —'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORh1ATION(continued) Property Address: 41 Smith Street Hyannisport Owner: Sacha Nearon Date of laspccllon: 2,7_—)3d0 i TIGHT or 110LD G TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad . Material of constiction:—concrete_metal fiberglass_polyethylene other(explaut): Uuncnsro:is: f Capacity:_ ( gallons Design Flow: ] gallons/day Alarm present Wes or no): Alarm level: I Alann in working order(yes or no):_ Date of last purrtTin : Currunents(c ndition of alann and float switches,etc.): DISTIVIDUTION BOX: L�(if present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert: Conunen!.s(none if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of - leakage into or out of box,etc.): O PUMP CRANIUM (Ioe'atc on site Ian Pumps in working order(y s or no):_ Alarms in working order yes or no):— Conunenis(note eondili it of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Smith Street Hyannispor Owner:_ Sacha Negron Date of Inspectional SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type r ' eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cessp ool must be pumped as part of inspection)(locate on site plan) Number and configuration` _ Depth—top of liquid to tltlet invert: Depth of solids layer: / Depth of scum layer: Dimensions of cesspool: Materials of construction. Indication of groundwater inflow(yes or no): Comments(note cod dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): _ PRIVY: (locat on site plan) Materials of cons ction: Dimensions: Depth of solids:1 Comments(noteicondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Smith Street Hyannisport Owner: Sacha Negron Date of Inspection: / /Z-o t� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. b Ll t3 1 - 3L 0 0� 10 J Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Smith Street Hyannisport Owner. Sacha Ne ron Date;of Inspection:/,7- -1 'G Ll SITE EXAM Slope Surface water Check cellar Shallow wells y Estimaied depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within ISO feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe howyou established the high ground water elevation: I1 U —;,,, CO:�S_N20\NN'EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRO MENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION? ONE RZNTER STREET, BOSTON 0210E (61,) 292-550u TRUDYCONE Secretain• ARGEO PAUL CELLUCCI DAVID B STRL-?iS Governor Comaussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 41 Smith St . , Hyannis portNameof.Owner Gerald. Selby Address of Owner: 20 Longf 1 1 ow nr , r DateofInspection: $-3-4 9 Yarmouthport, NIA 02675 Name of Inspector:(Please Prirrt)Wm. E . Robinson Sr . 1 am a DEP approved system!inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) CompanyNamre: Wm. E . Robinsoneptic Service Mailing Address: PO Box 1089, Centerville, NIA Telephone Number: -7-rJ 5�8�7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails 01 Inspector's Signature: "V L b r Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner _shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS �t N G OCT 1 5 1999 revised 9/2/98 Page Iof11 ;� �r:rred on Recycled Papa . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) "rap"Address: 4.1 Smith St . , Hyannisport OM1t1w: Gerald. Selby Date of Inspection: ^l INSPECTION SUMMARY: Check( J B, C, or D: A. SYSTEM PASSES: v v I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. STEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion'of the replacement or repair, as approved by the Board of Health, will pass. Indicate y s, no, or not determined (Y, N, or ND).' Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed • , r 9 h � revised 9/2/98 Page2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Smith St - , Hyannisport owner: Gerald. Selby Date of Inspection: D. SYSTEM FAILS: You rNust indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within,50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE YSTEM FAILS: You must ind ate either "Yes" or "No" to each of the following: The ollowing criteria apply to large systems in addition to the criteria above: The s stem serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health nd safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or oper for of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Depa ant for further information. revised 9/2/98 Pagc4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 Smith St . Hyannisport Owner: Gerald. Selby ° Date of Inspection: `f-3_Q 7� C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of.Health in order to determine if the system is failing to protect the p blic health, safety and the environment. 1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 41 Smith St . , Hyannisport + ° Owner: Gerald. Selby Date of Inspection: 4'-°3-4 0i Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No ✓/ _ Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ° ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. v _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper rnaintananca of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iroperty Address:41 Smith St . , Hyannisport Owner: Gerald. Selby Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. l Number of bedrooms(design): ff-l/ Number of bedrooms (actual) Total DESIGN flow 4mo -SRO Number of current residents:�A Garbage grinder(yes or no):, y Laundry(separate system) (yes or no):A; If yes, separate inspection required. Laundry system inspected (yes or no) Seasonal use(yes or no):,oA-0 Water meter readings, if available (last two year's usage(gpd): 1998 45, 000 gal. Sump Pump(yes or no):Ld Last date of occupancy: �'i=3-g 57 1997 39, 750 gal COM RCIAL/INDUSTRIAL: Type of stablishment: Design fl w: gpd ( Based on 15.203) Basis of d sign flow Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water me er readings,if available: Last dat of occupancy: OTHER-(Describe) Last d ccupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /4 q, G System pumped as part of inspection: (yes or no)_C) If yes, volume pumped: gallons Reason for pumping: TYPE /SYSTEM ��/// Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Y%=-Jr Sewage odors detected when arriving at the site: (yes or no) C� revised 9/2/96 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimmd) IropertyAddress: 41 Smith St . , Hyannisport x Owner: George Selby Date of Inspection: BUI ING SEWER: (Locat on site plan) Depth elow grade:_ Mated I of construction:_cast iron_40 PVC_ other(explain) Distan a from private water supply well or suction line Diame er Co. ants: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: 1 Material of construction: Loncrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ °t Sludge depth: 1 I Distance from top of sludge to bottom of outlet tee or baffle:•t/ Scum thickness: 3—C_'1 J I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outl�tee or baffler How dimensions were determined: 1 'omments: (recommendation for pumping, condition of inlet and gutlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 0-0 '6 �' / T A-/e 1.11 s j+ d t 10 5ca t'r GREA TRAP: (locate o site plan) Depth brn ade:_ Materiastruction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimens Scum ts: Distancop of scum to top of outlet tee or baffle: Distancbottom of scum to bottom of outlet tee or baffle: Date ofmping:Comme(recomon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidenckage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued). 'roperty Address: 41 Smith St . , Hyannisport , Owner: Gerald. Selby Date of Inspection: 9 -124 7 e TIGHT HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o site plan) Depth belo grade:_ Material of construction:_concrete_metal Fiberglass_Polyethylene_other(explain) Dimensions. Capacity: gallons Design flo gallons/day Alarm pre ent Alarm lev I: Alarm in working order: Yes_ No Date of p evious pumping: Comme s: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) �y Depth of liquid level above outlet invert: V Comments: (note if level and distribution is equal, evid of solids carryover, evidence of leakage into or out of box, etc.) - PUMP CHAMB (locate on site p an) Pumps in worki g order: (Yes or No) Alarms in worki g order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 4.1 Smith St . , Hyannisport Owne;:, Gerald. Selby Date of Inspection: 5_3 s7 S / SOIL ABSORPTION SYSTEM(SAS): l/ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hgdraulic fail level level of podding, damp soil, condition of vegetation, etc.) CESSP LS:_ (locate o site plan) Number an configuration: Depth-top o liquid to inlet invert: Depth of soli s layer: depth of scu layer. Dimensions o cesspool: Materials of c nstruction: Indication of roundwater: inflo (cesspool must be pumped as part of inspection) Comments: (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on ite plan) Materials o construction: Dimensions: Depth of so ids: - Comments: (note Condit on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 4.1 Smith St . , Hyannisport a )wner: Gerald. Selby Jete of Inspection:�`7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within.100' (Locate where public water supply comes into house) f 1 l y3ce :4 rev_sed 9/2/98 Page 10of11 I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rope"Address: 41 Smith St . , Hyannisport Owner: Gerald. Selby . Date of Inspection: �-3�g9i NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells 1 Estimated Depth to Groundwater j Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF 12, a DEPARTMENT OF ENVIRONMENTAL ONE WINTER STREET. BOSTON, MA 02108 6.17-29 - 0 OCR- F�F� WILLIAM F.WELD ojyN � � T UDY CORE Governor �Fq�jEq p 9g �,9� Secretary ARGEO PAUL CELLUCCI e1, ti�Nrr�F I)A D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 41 Smith St, Hyannisport Address of Owner: Gerald Selby Date of Inspection: 9—/0 - Q 'd (If different) 20 Longfellow Dr Name of Inspector: Wm E Robinson Sr Yarmouthport,MA 02675 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:. Wm E Robinson Septic Service Mailing Address: PO BOX 1089 , Centervi 1 1 P,_MA 02632 Telephone Number( 50 8 j 7 7 5_R 7 7 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: t/Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: e,h Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below, COMMENTS: B] YSTEM 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. In 'sate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the-septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ¢t (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpJtwww.magnet.state.ma.us/dep Printed on Recycled Paper r - p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Smith St, Hyannisport Owner: Selby Date of Inspection: q —1®—q I B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] URTHER 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 the public health, safety and the environment. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Smith St, Hyannisport Owner: Selby Date of Inspection: q-14-4' t ) SYSTEM FAILS: Y must in easier "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) RGE SYSTEM FAILS: Yo must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone 11 of a public water supply well) The o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program regUir ments of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rSvinad 04/25/97) Page 3 of 10 If` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Smith St, Hyannisport Owner: Selby Date of Inspection: 4 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. c 119 _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. c1e s _ The system does not receive non-sanitary or industrial waste flow. y _ The site was inspected for signs of breakout. y _ All system components, excluding the Soil Absorption System, have been located on the site. sep tic tic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of _ P baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 Smyth St, Hyannisport Owner: y� y Date of Inspection: Ze Ob ca 7 FLOW CONDITIONS RESIDENTIAL: Design flow:"/"/0 p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:429 Garbage grinder (yes or no): /? o Laundry connected to system (yes or no):�;y Seasonal use (yes or no):2o Water meter readings, if available (last two (2)year usage (gpd): 7/9 5 7/9 6 — 7 4 , 2 5 0gal s Sump Pump (yes orno):yy 8/96 - 7/97 - 63, 750gals Last date of occupancy:2-1d_ COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Syst6A pumped as part of inspection: (yes or no)_ If yes, volume pumped: Rallons Reason for pumping: TYPE OF STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: fA 4 °C 6 9- f 4 7 S tom•IS �a/alu� Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Smith St, Hyannisport Owner: e b Dateoy_� Date of Inspection: BU DING SEWER: (Coca on site plan) Depth low grade: Materia of construction: _cast iron _40 PVC_other (explain) Distan a from private water supply well or suction line Diam ter en Co ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locate on site plan) Depth below grader , Material of construction: ✓—concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 6 Sludge depth: i Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: /0 r' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: '1-6 How dimensions were determined: r jft� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in r anon to outlet invert, structural integrity, evidence of leakage, etc.) �-� 1� Gv a ✓� iC (' 1 '+'^ -P1.4 v GREA TRAP: (locate n site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen ions: Scum hickness: Dist rice from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Comme ts: (recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Smith St, Hyannisport Owner: Selby Date of Inspection: 7-/S_$-7 TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (local on site plan) Depth low grade: Mater' I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen 'ons: Capaci gallons Design low: gallons/day Alarm evel: Alarm in working order_Yes; _ No Date o revious pumping: Comme ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Q Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) / PUMP CHAMBER:_ (locate on site plan) Pum in working order: (Yes or No) Alar s in working order(Yes or No) Com nts: (note)ndition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Smith St, Hyannisport Owner: Selby Date of Inspection: g —/S / SOIL ABSORPTION SYSTEM (SAS): t/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:-9-- leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of by raulic faaii ure, level of ponding, condition of vegetation, etc.) l,.S t?i jley 40 �',•+.L t r CE)ae OLS: _ (lon site plan) Nand configuration: Dep of liquid to inlet invert: De solids layer: Dscum layer: Dions of cesspool: M of construction: Inn of groundwater: inflow (cesspool must be pumped as part of inspection) Comme ts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Materi s of construction: Dimensions: Depth solids Comme s: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zaviaad 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: '41 Smith St, Hyanni 'Sport Owner: Selby Date of Inspection:A3-•/,S-1 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) � t , J (roviaad 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4.1 Smith St, Hyannisport Owner: Selby Date of Inspection: Depth to Groundwater J01 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) E (revised 04/25/97) Page 10 of 10 L0CATI N A SEWAGE PERMIT NO. VILLAGE IN 6 LLEi'S NAME i ADDRESS s%ID ER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE - ISSUED �-) � t f ► I it n No.�_—7 29-�S' ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF........................................ ............................................. App irntion for Uiipnsal Mirkii Tundrurtion ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( - an Individual Sewage Disposal SYst �/1}.at_ /t'�J. � ....... ......................................................... •••••-•--••-•••--------- 7 Locati iTt Ad s or Lot No. Address (� / L ' Installer Address T e of Buildings Size Lot.........._______________ Sq. feet 2 Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `� Other—T e of BuildingNo. of ersons____________________________ Showers — Cafeteria a Other 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_ ____________________ 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........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit..................__ Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.------------------- Depth to ground water........................ aA ----•------r.X................................................................................... Description of Soil ------1-1: . x W --•--------------------------------------------------------------•. - ------ x Nature of Repairs or Alterations—Answer when applicable.________ ._ l�` 1� � �✓1✓.__'_______________________________________________ U P ----------------------------•-------.....------------ -----...------------------------------------------.... -_. ....------------------------------------.._..----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI2 5 of the State Sanitary Code 7— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by e bo d of ealth. Signe ----- -- ._... _ .. ....... ........ �( n' 4Application Approved By_---= y at -- --•--- Date Application Disapproved for the following reasons----------------•---------------------------------------•---•----------------------------------•--------------- ......--•-•----------•-----...-•----•------------------------•-•-•--.._......-----------••-•----....----------------------------•------.----•----------------------------------------------•------------ Date Permit No........ �_-� `�` Issued �. .$ -------••---_... Date No. FEs............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr . ...........OF........ ................ Appliration for"Di pau al Works Toustrur#inn amit Application is hereby made for a 'Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ........... __ Y K Local Address or Lot No. 1J ,r'4` ? ... q-.,.i�-f ...a-ts., .(.:.o l.'!.6i.<r ........... ......... .............. ............................... .............--...............--.............--. } 4 Owner x Address t....._ J�'t,: .:�'... : '_Z.......... .................................................................................................. �..._.. Installer Address .� Type of Building Size Lot...........................Sq. feet �-, Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder '4 Other—Type of Building No. of persons............................ Showers R ' P.1 yP g ---------------•--•------... ( ) — 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...................... 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-----------......................................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd . DDescription of Soil--------. -----------------------•---..:..--••---•---•----•---------------•-----------------..................................................... W U -----•-•••---•-------•-•--•--------•-•••---------------------•---------------------•.........-•----.....------•-------------•---•--•--------------------•----------------------------....-•------------- W -•------•--•---------•-------•----•-------•-•••--•-••------- • . --------•-•----------------------------------------------- . U Nature of Repairs or Alterations—Answer when applicable.-,e�'`-__., "____� fix:s .............................................. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beet). issued by the board of health Signed- ""Air .: r A lication Approved B '�_. .!...�........ ^. _.._....... - ` rr rr y----- Date Application Disapproved for the.following reasons---------------•--•---------•----•-=------•-•----------•----------......----•--•--------....................... ......................•.......---....---:-•-------••---------------------....------------.......----•----..................------•---------••--------••----- -----•---•-••--------•-------•------....._._ / Date Permit No: Y�... . ..a...15---------------- Issued............. . .... yl........... ate ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. Trr#ifiraa#r of ToutpliFanrr T IS S T, �ERTIFY, That the Individual Sewage P'lsposal System constructed ( ) or Repaired } /J f1 '� - /°!"Cc `�%.r is"l`�w ..ding.... �, f Installer at....... sin G o � has been installed in accordance with the provisions of TITLE•,..,�`�•of Th S,�ate Sanitary C e as de i din the application for Dis osai Vorke Construction Permit No._...... - dated_-.._ � PP P ...>.....--•------ --• _...--------•-- ' THE ISSUANCE OF,THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM VIAL FUNCTION SATISFACTORY. i DATE.......... / .._---------•------...... Inspector....I..a------------------------------------------------------------•-----••-- l �� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF- HEALTH - ...,,.. ........... FEE........................ ,rk,v Toni wan rrzatt Permission is hereby granted ¢ J . t_'�"r r r . . -• ' = +'=/1,' e ��c to C.00nstruct�. ) o Repair an r'Individuaj-Sewage Disposal System at No 'i �....�?YY. .: t ? f ir.......................................... -`- tree ____ J_s_ !-�` 03� a,, as shownOn the application for Disposal Constrrlerm o______________ __ y`�� ----- ---- ------ --�----------------- ----- -------- �.( Board of Health DATE------.q•.... ......... .....----.......-------------...--- S FORM 1255 A. M. SULKIN, INC., BOSTON k .:TOWN OF BARNSTABLE LOCATION �� J �j III SEWAGE# VILLAGE ;r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. O SEPTIC TANK CAPACITY d 4EACHING FACILITY: (type) �/ G - r�v� (NO.OF.BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATr- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ' <� r .. •� �. f._ e � . � � � � � 1 � � _ s. �� .r HYANW. MA PLAN REFERENCE f CONTOURS SMTH STREET Z PLAN BOOK 86 PAGE 127 EXISTING == - - 20 GLEN ASSESSOR'S MAP: 288 MINIMAL GRADING PROPOSED LL¢ �< ROAD LOT: 14 00 0� fOND� ir H2O o<F a �Hs LOCIRS c =o o<0 I C Lh N N BENCH MARK aD z PK NAIL IN DRIVE L O C US M-A P , o ELEVATION - 16'.52 �Q NOT TO SCALE o�N USGS DATUM ASSUMED LU } a: w J� LL z � � 1",4v � � � LEGEND N LL = W w p P�c W xcl: o J o / ,``.01 {; �R�� EXISTW1000GAG N LU w 6 i I �� SEPTIC TANK W z J 0 /5 P P �� a 0 D-BOX 0 3 �: �P� oo -10 TEST PIT J X _ I S � EXISTWG GAS LEACH PITco Z � w � / �_I GATE cr- W J >LL 15 - UTILITY POLE $ J U r o w / `/ ��, �� < 2 LOT l i AREA - 9025 S f +— Li 0000 / I A I oo. z -� 132.00 I z � � oz �t PLAN N LL z J � t' 1 /6 O z 0 U `—SOIL REMOVAL AREA SCALE: i = 20 ft SEWAGE DISPOSAL SYSTEM PLAN +. �� 6D X O cL 31 ft x 12 ft x0.96 ft —TO SERVE EXISTING DWELLING o p LEACHING GALLERY MICHAEL & SACHA NEGRON q ° 1 �� 41 SMITH STREET HYANNIS. MA LL 9 _ z �°� ECO—TECH ENVIRONMENTAL qqO ? ►- '. w 43 TRIANGLE CIRCLE SANDWICH MA 0256 W 508 364-0894 '� - � �� ps ETE-1978 APRIL 19. 2005,, 1/2 ` /` THIS PLAN IS TO BE CONSIDERED A DRAFT KLAN UNLESS R BEARS TIf STAMP AND SIGNATURE OF :_T}E:DESIGN ENGINlEER . ORIGNAL PLANS INTENDED.FOR SUBMITTAL T0.TFE-BOARD OF.HEALTH-.WILL BE'SIGNED N BLUE°AND`STMPED N RED. 1 IL TEST LOG PATE OF TEST: APR�L 11, 2005 DESIGN C ALCUL ATI-ONS SOIL'-EVALUATOR: DAVID D. COUGHANOWR. RS WITNESS REQUIREMENT WAIVED NO VARIANCES SOUGHT GROUNDWATER ENCOUNTERED AT 112 in TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH 1 DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD PERC AT 78 in 2 MIN/INCH IN C SOILS ELEVATION - 16.13 +- _ , SEPTIC TANK: t'330 PD X 2 DAYS 660 _�7ALLONS T DEPTH SOIL USDA SOIL SOL COLOR SOL OTHER u52 EKl Stf Kff (dD� f-tllpn �c- Air c Terra t, (T to SOJ,,a( 5"`I vc�vYtil Cc c(' b1rJ� (r -ES) HORIZON TEXTURE QIJNSELL) MOTTLING INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) 16J3 0-8 FILLDISTRIBUTION BOX: USE 3 OUTLET D-BOX. 8-16 Ap ' WOOD LOAM 10 YR 2/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 31 ft x 12 ft x 0.96 ft LEACHING GALLERY CAN LEACH 16-42 Br LOAMY SAND 10 YR 4/6 NONE LOOSE Abot - (31 x 12 ) - 372 of 6.80 v 12-130 C MEDIUM TO ID YR 6/4 NONE LOOSE A s d w - ( 31 + 31 + 12 + 12 ) x .96 - 82.56 s f 5.30 COARSE SAND A t o t - 454.5 s f Vt 0.74 x 454.5 - 336.3 GPD USE A 31 ft x 12 ft x O.96 ft GALLERY. Vt - 336.3 GPD > -330 GPD REQUIRED GROUNDWATER ADJUSTMENT OBSERVED GW: 6.80 LEACHING GALLERY CONSTRUCTION INDEX WELL: MIW-29 — DETAIL ZONE: B - READING: MARCH. 2005 c - SHOREY MFG FD 4x8-S LEVEL: 7.1 FLOWDIFFVSOR ADJUSTMENT: 1.4 ft LEACHING UNIT OR ADJUSTED GW: 8.2 EQUIVALENT STONE 8'-G-x 4'-G-x I'-6- 11.5 in EPP. DEPTH 31 f t y NOTES V 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 3 5 8 8' 8' _51, 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL COMPONENTS INSTALLED SHALL .MEET THE MINIMUM REOUIREMENTS 31 f t OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING LEACH PITS TO BE PUMPED. COLLAPSED. AND REMOVED. CONTAMINATES _ SOILS ARE TO BE REPLACED WITH CLEAN MEDIUM SAND. : 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN - SEWAGE DISPOSAL SYSTEM PLAN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS, THE'0tT"ALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE ' SEPTIC TANK -TO SERVE EXISTING DWELLING 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR eLOADING. DO NOT MICHAEL & SACHA NEGRON PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. x . 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT .BE'1=0RE STARTING WORK. 41 SMITH STREET HYANNIS. MA 11) SEPTIC TANKS SHALL BE INSTALLED LEVELi--AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY�COMPACTED AND ON TO WHICH ECO-TECH ENVIRONMENTAL SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 12) UNSUITABLE SOILS ENCOUNTERED WITHIN THE SOIL REMOVAL AREA, ARE TO BE 43 TRIANGLE CIRCLE SANDWICH MA 02563 REMOVED DOWN TO THE C LOAMY SAND STRATUM AND REPLACED WITH CLEAN ' MEDIUM SAND AS ''PER TITLE 5. ETE-1978 I APRIL 19. 2005 1 12/2