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Home My WebLink About0010 STRAIGHTWAY - Health ?f0'aStrar�f�t'wra�- : X Hyannis P ! A = 267 123 J I t G r T J C 1A \N TOWN OF BARNSTABLE Locki,ION SEWAGE # VU 'AGE &n _ASSESSOR'S MAP& LC� �a a INS'fAi.LEk'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1660 IKOC A 4 LEACHING FACILITY: (type) / (size) NO.OFBEDROOMS BUILDER OR OWNER PERMUDATE: -GOMPDXNCE 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 wetl exist within 300'feet of leaching facility) , ` Feet Furnished by 7 L 7 a �a U TOWN OF BARNSTABLE LOCATION 1't SEWAGE # VILLAGE A S SOR'S MAP & LOT INSTALLER'S NAME&P NE NO. SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 'COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p sa 4!a �n � ® S� � �� a u� s � ^ `� n n n. � n d �� .�.�w -C ..0 S �� +,� I OF BARNS"1 ABLE I A LO TION I O STr-AI L Gv SEWAGE # VTLLI:AGE N4M'1lS ASSESSOR'S MAP & LOTS-�� Z. ati INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY' (type) yX� I0,T (size) l�OD NO. OF BEDROOMS 3 _.,�� BUILDER OR OWNER .JlgASC l PERMITDATE: 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 within 300 feet of leaching facility) J Feet Furnished by 'T%I sOuTiy� T FO/G l ef J �4 19 .9 r� r, M lq O ROA _LO.C&TIO.N ____.___ ____ SEWO C-,E PERMIT__1J0. A _I1`1-STILLER f`l� E ADDR Ss . _ _BUIL_DER 5 _tJ.&"F-._ AD..DRE.SS- DACE_ PERMIT DATE _COMPLI WACE ISSUED ; `' ,��s �+ - � u- Health Complaints .26-May-04 Time: 10:16:00 AM Date: 5/21/2004 Complaint Number: 17434 Referred To: DAVID STANTON Taken By: DENISE WITTER Complaint Type: GENERAL Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 10 Street: STRAIGHTWAY Village: HYANNIS Assessors Map_Parcel: Complaint Description: CORNER OF SMITH STREET AND STRAIGHTWAY AND BARNSTABLE WATER COMPANY PROPERTIES. CALLER SAID IT LOOKS LIKE GRAY WATER. CALLER SAID A FEW YEARS AGO THERE WAS A LOT OF GRAY WATER BUT THEN IT STOPPED BUT NOW IT'S THERE AGAIN. CALLER SAID IT'S A DRAINAGE BROOK AND DRAINS INTO HALL'S CREEK. ;Actions Taken/Results: DS TRIED TO CALL COMPLAINANT, NOT HOME. DS WANTED TO MEET WITH COMPLAINANT TO SEE EXACT LOCATION. DS WENT TO SAID LOCATION. DS DID NOT OBSERVE ANY GREYWATER OR ILLEGAL PIPING INTO THE CREEK. DS WILL ATTEMPT TO CALL COMPLAINANT AT ANOTHER TIME TO RE-INVESTIGATE. S CALLLD COMPLAINANT. DS VISITED COMPLAINANT, WHO GAVE.HIM A MA OF LOCATION. DS WENT TO 10 STRAIGHTWAY, NO ONE HOME, DS TOOK A LOOK FROM THE DRIVEWAY, BUT COULD NOT SEE THE CREEK. DS WALKED DOWN THE TRAIL FROM THE OPEN 1 Health Complaints 26-May-04 SPACE. DS DID NOT OBSERVE GREYWATER. DS WILL ATTEMPT TO GO BACK OUT WITH SOMEONE ELSE TO INVESTIGATE. THE CREEK MAY BE ON PRIVATE PROPERTY. THE GUY SAYS IT MAY BE FROM THE SAME PLACE THEY HAD PROBLEMS IN THE PAST AT MR. DALEYS HOUSE ON WEST HYANNISPORT CIRCLE. Investigation Date: 5/24/2004 Investigation Time: 4:10:00 PM 2 TopoZone- The Web's Topographic Map http://www.topozone.com/print.asp?z=19&n=4610625.... J . F: wAD F r lip N. x ' 4If I I w IvIIIII 0 0.07 0.14 0.21 0.28 0.35 km M G 0 0.05 0.1 0.15 0.2 0.25 mi Map center is 41.63990N, 70.3097°W (WGS84/NAD83) Hyannis quadrangle M=-1s.86$ G=-o.e7 Projection is UTM Zone 19 NAD83 Datum 1 of 1 5/21/04 11:11 AM ;r-.�; ''�',�..l .. ', . �.e '� � ��'`Y.�`air -�,i.''�• ,,r�'.. ION t �' .�4"` +s. y sips€��}+• �fi., ��,. �4T Z , �s y T ... h 1 ' a r ) •y � ,�• � �x; x� , f � Tara, y�.. J r , IN � �� Y r� Y_ • � A ir Ij op lip 1 �•r , ' J � r•� y A �N .i •f�L �s �.4 r� 'r;,: � {f j. ..,� .�,�� y a£i •� �,.� � `'�. ' 1` � '...ill—{,� �+' 1 w � .. y P !�f k J � t �- ,` 4� ,� n� �� trbYr 1S t 1 �,t",'`y f +,i'' 1!'•S ��.� � ,�� v�r� f �ty l^ S•+P 'S`P� ? .y"t' `L�-.�. - y� �.4i.T,P""'• "�r � 1��y t�j�f� J�yr, •s, j� ~ ;err .. 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't �j."�`y 4 y --."'T.3 .7'4 _��J�+- �± •y.5� " V.—AO• ': ��' :fir t�, y.��X r 1'•♦ a ta-S � '� `E,•F. � ��kY �x r � sY ' - °.. � ,.„J 2at�►- • '`4 i %",�.>figs-` ' .�4 v , *c COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION '�sawl,r.,em,„am�,: TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Straightway Hyannis. MA 02601 Owner's Name: Kellie Jansen' Owner's Address: 713 Oueen Ann Road Harwich,MA 02645 Date of Inspection: April 19, 2005 Name of Inspector: (Please Print) James M.Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 -Z CD 2-1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the in ormation reported below is true,accurate and complete as of the time of the inspection. The inspection was perform d based o my cd training and experience in the proper function and maintenance of on site sewage disposal systems I am q6EP I,— approved system inspector,pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syst in: ✓ Passes Conditionally Passes ` 4' Needs Further Evaluation by the Local Approving Authority Fails � t Inspector's Signature:T Date: AlZril24, 2005 The system inspector shall sub 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. `* Notes and Comments '{ **** This report only describes conditions at the time of inspection and under the conditions of use at that A ,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 4 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Straightway Hyannis, MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 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. ND explain: 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 obstruction is removed 5.; w distribution box is leveled or replaced ND explain , ' 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 k . obstruction is removed ND explain: 4 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Straightway Hyannis. MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 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 2. System will fail unless the Board of Health and Public y ( b c 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 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. 3. -Other: - 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Straightway Hyannis, MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia a 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.] No (Yes/No)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 System: To be considered a largefsystem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 • th4e`system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped = 4 ZoneJI1 of apublic water supply well F * =aF - If you have answered'`yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under.Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Straightway Hyannis, MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 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? 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 ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Strai—ahtwav Hyannis,MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable-Pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): 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 1 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: Installed approximately in 1989-per information on file Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straightway Hyannis, MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 7" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage The tank was pumped for maintenance after the inspection. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straightway Hyannis. MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. t PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): J+tkS Ii F xr t 8 i• Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO�AL SYSTEM INSPECTION FORM PART C SYSTEM INFO TION(continued) Property Address: 10 Straightway 7 Hyannis, MA Owner: Kellie Jansen Date of Inspection: Aril 19 2005 77 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on sit plan,excavation not required) I If SAS not located explain why: I i Type ✓ leaching pits,number: 1-4'x 6'(600 ga1,) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of techno ogy: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach nit had Y ofliauid on the bottom. There did not appear to be any signs offailure The bottom to grade was 8' The cover was 2'below grade. CESSPOOLS: None (cesspool must be pumped as part of it spection)(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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction:% Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,le el of ponding,condition of vegetation,etc.): y • v Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straikhtway Hyannis. MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 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. O a 0-- 3 , a ao y/6 a a� vS 3 tG a(0 10 0 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straightway Hyannis, MA Owner: Kellie Jansen Date of Inspection: April 19, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 10+/- 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 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing gpproximately 10+/-to ground water at this y site. This report has'been prepared and the system inspected and passed as of the date of inspection. This report is y,'-not a warranty or guarante gua e that the system will function properly in the future. There have been no warranties ,q or rantees, either expressed,written or implied, relating to the system, the inspection and/or this report. ift � ,s COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z W DEPARTMENT OF ENVIRONMENTAL PROTECTION M A Y �O�M Vov`Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner's Name: ROBERT ELDRIDGE JR ^ -7' / Owner's Address: P O BOX 1221 DENNIS MA 02638 0( Date of Inspection: 6/4/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 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: X Passes _ Conditionally asses _ Needs Fu Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/4/01 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. 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. Notes and Comments- SYSTEM PASSES TITLE V INSPECTION. RECOMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ""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. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. 't 0' Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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. ND explain: n/a n/a 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 obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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): S broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require fiirther 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 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 n/a "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. 3. Other: n/a F Page 4 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM"INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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.i.A copy of the analysis must be attached to this form.) (Yes/No)The system tails. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks 9. X _ Has the system received normal flows in the previous two week period'? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(se ats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1989 Were sewage odors detected when arriving at the site(yes or no): NO F t Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 „ BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments( q 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.): DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 STRAIGHTWAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 4' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS ARE STRUCTURALLY SOUND AND APPEAR TO BE FUNCTIONING PROPERLY.THE PIT SHOWS NO SIGNS OF HYDRAULIC FAILURE. BOTTOM IS 8 FEET CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 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. I v 6 � B R 4 1 A, qj� A P� IL y BD ��b CA a Lis� c0 'a� in Page 11 of 1 1 v a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 STRAIGHTWAY HYANNIS,MA 02601 Owner: ROBERT ELDRIDGE JR Date of Inspection: 6/4/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-10+FEET — — 8,11999 �*7 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEG PAULCELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 10 Straight Way Hyannis Map 267 Par 123 Name of Owner n/a Address of Owner: Ruth Clark Date of Inspection: 1/26/99 Name of Inspector:(Please Print)John Graci l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (508)664-6813 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: X Passes Conditionally P s. s _ Needs Further v luation By the Local Approving Authority Fails Inspector's Signature: Date:1/26/99 The System Inspector shall ubmit 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 The system passes Title V Inspection.Recommend pumping system every two years to prolong the system's useful)life. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1125/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 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: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. NO 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. NO 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 NQ 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1126/99 C. FURHTER 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. 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 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 nLa_(approximation not valid). 3) OTHER nLa K I revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/26/99 D. SYSTEM FAILS: You must 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 No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/26/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of inspection:1/25/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):Wa Total DESIGN flow: Wa Number of current residents:Wa Garbage grinder(yes or no):flL0 Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):DLO Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NO Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no):CIO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MO Water meter readings.if available:nLa Last date of occupancy: Wa OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):MO If yes,volume pumped nLa_ gallons Reason for pumping: n/A TYPE OF SYSTEM XSeptic 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: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: System was installed within the last 5 years. Sewage odors detected when arriving at the site:(yes or no): MO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/25199 BUILDING SEWER: (Locate on site plan) Depth below grade: Z. C Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: Z' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nLa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: L" Distance from top of sludge to bottom of outlet tee or baffle: 3r Scum thickness:I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: A How dimensions were determined: MEASURED Comments: (recommendation 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:-nLa Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: n& Comments: (recommendation 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.) nLa i revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/25/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Wa Dimensions: Wa, Capacity: Wa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:_V& Alarm in working order:Yes_No_: NO Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/26/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Wa Type: leaching pits,number: nta leaching chambers,number: _nLa leaching galleries,number: ja& leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) DID NOT EXPOSE SAS APPEARS TO BE FUNCTIONING PROPERLY,FROM INSPECTION OF D-BOX. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n(a Depth of scum layer. Wa Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n(a Depth of solids: nfa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 - Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/25/99 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) n/a d ci r- g c b Ag AC 3 a 111 (DC N� revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Straight Way Hyannis Map 267 Par 123 Owner: n/a Date of Inspection:1/26/99 NRCSReportname: nLa Soil Type: nta Typical depth to groundwater: n& USGS Date website visited: nLa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 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 XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS r - ; T @aaT revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE LOCATION 0 5 j � 1,vvf SEWAGE # T9 6 � I VILLAGE ��/Y J ��' _ A S:F SSOR'S HAP LO'Ti _ J. CRAIG MEDEIROS �n INSTALLER'S NAME 67 PHONE NO. 78_ DN STI YANNIS, MA 0260r SEPTIC TA14K. CiXPACITY�� xt LEACHING FACILITYAupe" /� S—� size) �NO. OF BEDROOMS � —PRIVATE WELL OR PUBLIC WA'Tii . aUkH5t OWNER DATE PERMIT ISSUED: 1116�d DATE COZIPLIANCE ISSUED_ . ,!,VARIANCE GRANTED: Yes No >.' , • , 6 �fl k `AA s �J� X � �' y �� ! O� �, 6� L3 " �� No..d.. ..�� Fiz$.9�'.:.".. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Disposal Works Tnnstrnrtiun ttrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( blj""an Individual Sewage Disposal System at: � 0 �'f'.. t Gi f w,a •---......•.... ----•------------------------------------------------------ ••-..ocatio (Addr f or Lot No. ........ .... ._...._._61 !,?.... -l_. ..................... ? .....��... `..... ............._..... wner Ad ress Installer kciftress PQ Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ...... ........................... W Design Flow............................................gallons per person per day. Total daily flow........................._..................gallons. 0x Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—NTo. .................... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----------------_------ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix [-------- ----•-•-•-•------- ......•------------------------•------------------------------------------•-------------------------------- O Description of S oil........... 'T.ra-� �" --------------------------------- -------------------------------------- •------------------------------•---------------- V •--••----•••-•--••............••••••......------ --------------------------------••---......._ ------------------------------------------------------------------------------------------------------------------------------------------------------------ •••- U Nat f Re or Alterations—Answer when appl'cable.--- -•_..0. __ ��✓� ` 'J ...... ---- --- ------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii�'�_ p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. "Signed-5.17 �� !...._ .Application Approved BY ................... 1 ........ Date Application Disapproved for the following reasons-........................................ --•--••-•---•-----•-•-•-•--•---•-----••-•---•----•-•-•-•----•------••-•-.....---•------------------•-•--•---•-••-•-----••--•--------------•-------•---•--•••---•••--•---••--•------•--•---••--••-------- Date Permit No.-. ......................................... Issued_............ ......./ .. Date No..�L___.. � 1 FB. /6I r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... . i...............OF..... ....... Apli iratiou for Utipuaal Works C omuu.; tun Pumit t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a ,� ,t ..........................« .._._ ..__... L .�._......«._. � t/�Lg1ationK'°Addre�`s� ( / .:. { ' " , '............... 't..'�' -- — = ......................... Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers Ga YP g ------•-•----•-------------• P ( ) — Cafeteria ( ) al 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—NTo. .................... 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........................................ a a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd D Description of Soil --.....=-•�- --------- -------------------------- •---------------------------------------------------------------------------------------- U ----•----•--•---•-•-----•-------•----•--------------------------- ---------•-...•---••--•-------•---•-•-------•-----•��- •----- a t U Nature-of-Repairs-ofAlterations—And r w e . a-bplic 6t&-------- ------eil-- -- ------ --- ---- --------- --------- ------------------- - ------------ : - -••---. ----------------------------------------------------------------------------..--------••-------•--•-•----------••--•-----•------•---..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with (••IT!'IF^ the provisions of 1 T t:.=: j of the State Sanitary ode=•-,The undersigned further agrees not to place the,sys,ee-m— i operation until a Certificate of Compliance has beexi'ptsued by the`bo'ard of,health.=. 'C% " ! igned- - 1= ' ----------------------------------------------- Application 7 Approved By............................................................................•--•- -� Date r'1 Application Disapproved for the following reasons--------------------------------------------------------------------------------•--------------••......---_.._.. - Date " PermitNo.--��......................................•-- Issued.----....------------------- -....---•------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF—HEA�LTH�- ..........................................OF......b:%.....................................................................-•--• " ThdAh'e^-Int;V- idual Sewage Disposal System constructed ( ) or Repaired ( _ } by....... +. _ :ram... � ".. r - �_:r- - -----� ! ! . ,,f1?,�... ....._... .1 a..='i....�.r ,at " InstSller �:_ I ,ycr__ -....--•--•••••---•--•-•---.....-•--•--•••-•------•-•r----••....... has been installed in accordance with the provisions of TIT of 1pte Sanitary C?�7� the aQ /application for Disposal Works Construction Permit No.--- . dated-----•- ----•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... held__ -•----------•-----....--•--...... Inspecto ----=� --�... -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF IIAL -FI ..........................................OF........---.......................................................................... '+o`er'%o No...•-•---•............... FEE........................ • �t��la��t-1�u��.� 1,��- u�iunlertr--nt�t Permission is hereby granted...-'- .: / .� = = to Construct (,-� �or Repair'( t ) an Indivi ual sewage D>sposaI System5e; f atNo.. -----------------••-••---------------------- ••..•-•--•=------- ......• ' as shown on the application for Disposal Works Construction p Street �_ . tow . .. PP P /" f` ------•-•--- ---------------------------------------------------` ---------------- •---- DATE. ` _:r * * Board of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS