Loading...
HomeMy WebLinkAbout0100 STRAIGHTWAY - Health 100 S IP RAIGHTWAY,HYANNIS -- - - - _ A = 268110 TOWN OF BARNSTABLE LOCATION C � i `( SEWAGE.# VILLAGE A-4&,A U/�_ASSESSOR'S MAP & LOT — INSTALLER'S NAME&PHONE N0. pmw,,2�y� SEPTIC TANK CAPACITY Cf P LEACHING FACILITY: (type)"I �U MA<-' lkA (size) 10 NO. OF BEDROOMS BUILDER OR OWNERrn� PERMITDATE: Q000 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) Feet Furnished by C� O o Tl �i �cr ?� ` x / JD N0'1'�00'" d ! / Fee e�1—e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS 01pplica.tion for Migozal brmem Con!5truction Permit Application for a Permit to Construct( )Repair(t )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Ad or ot�io ccyy r` wner's Name,Adess and Tel.No. A�so�r's Map/PaVrcel staller�'s NNammeK ss Addr ,an el.No. v esigner's Name,Address an d T No. Type of Building: \ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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 o terations(Answer when applicable) LL 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 provisio of Ti e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss i o ea Signed Date o� Application Approved by 94 Date D_ Application Disapproved for the following reasons Permit No. �4®0° �' / Date Issued 4%, O.m 0,0 / Fee , °., Entered in com uteri � ' THE COMMONWEALTH OF MASSACHUSETTS p Yes . r" 't PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Mi!5pooar *potent Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location AdpreV or' of N wner's Name,Ad ss and Tel.No. Assessor's Map - stalle�s Name Address,and el.No. esigner's Name,Address and Te No. Type of Building: . Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( , ) Other Fixtures Design Flow 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 o Iterations(Answer when applicable) It1 (1r-` (A 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 provisio of Ti e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss t ' o ea . Signed Date 1 Application Approved by Date—p Application Disapproved for the following reasons Permit No. �� Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT , that t to Sewage Disp al System Constructed( )Repaired(✓ )Upgraded Abandoned( ) at o has been constructed in accordance with the p vi f T �thesposal S ste Construction Permit No. _ dated Installer Designer A The issuance of this permit stall of be > nstrued as a guarantee that the system-will function%as design'e-d. y,r Date I Inspector ll1 �f1 i�i / r1f --------------------------------------- No. lI� Fee _ '1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopool 6potem on5truction Permit. Permission is hereby nstruct Repair Upgrade Abandon ( ) System located at : � ��a l kA �.�51 bb� �C and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: i_ IV j o Approved by e 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) ereby certify that the application for disposal works construction permit signed by me dated p� �''i' 00 , concerning the property located at 0 43 "eets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed.f, • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ►—h• + B) G.W.Elevation )3 +the MAX. High G.W.Adjustment. l 1 = oQL© 3 DIFFE BETWEEN A and B SIGNE DATE: 1, [Please roposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert cU � � 1 � 1 �, =-� 1. _- �w 4 //0 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 100 Straightway Assessor's Map: 268 Parcel: 110 M M Property Address a+ Emma M. Alley G3'1 Owner Owner's Name information is / required for every Hyannis I' MA 02601 February 6, 201710 page. City/Town State Zip Code Date of Inspection �. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information J filling out forms �j# 3S— on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Rapid Response Company Name 155 George Ryder Road South Company Address B Chatham MA 02633-1621 Cityrrown State Zip Code 508 364-0894 1328 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 NOF,y�ssq ❑ Conditionally Passes ❑ Fails cy ❑ Needs Fu . EJOPRon Local Approving Authority COUG N WR ti N .13 q February 6, 2017 Inspector's Signatur FM INSPtiG Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 I . / V G�� Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 100 Straightway Assessor's Map: 268 ,Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every y rY page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The sccpe of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 oy 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. •�-0 , The septic tank is metal and over 20 years cld* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration o�tank failure is imminent. System will pass. inspection if the existing tank is replaced with•a'complying septi&ta.hk as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sourid; not leaking and if a Certificate of Compliance indicating that the tank is less than 20 geairs old is available. ' ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every Y rY page. Cityrrown 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 FIND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M a 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every _Y rY , page. 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 rio other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is required for every Hyannis MA 02601 February 6, 2017 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: [I ® 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- 10,000g pd. The system fails. I have determined that one or more of the above failure E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6, 2017 required for every y ry 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 dwe'ling 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): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): see note t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is required for every Hyannis MA 02601 February 6, 2017 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: A repair permit was issued in 2000 for a 1500 gallon tank and a 40 ft x 10 ft x 2 ft infiltrator leaching system, which meets the requirements for a three bedroom dwelling. No engineering plans were required at that time. 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 i Water meter readings, if available (last 2 years usage(gpd)): 91 gpd Detail: 2015: 33,662 gallons 2016: 32,914 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: not determined 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 Februa 6 2017 required for every y rY � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6, 2017 required for every rY 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: Age: 16+ years Certificate of Compliance for a new system was issued 3/8/2000 (Permit#2000-091 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: ee Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: f 0t Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 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: 10.5'x 5' x 6-1500 gallon Sludge depth: 6 inches t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6, 2017 required for every y rY page. Cityrrown 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 inches Scum thickness 1 inches Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? As built card Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not requireded at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every rY page. Cityrrown 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.): i 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.doc-rev.6/16 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 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every y ry , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert 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.): No adverse conditions observed. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 � required for every y rY i page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching gallery stone and no standing effluent or effluent contact staining was observed in the stone or overlying soils. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6, 2017 required for every y ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6, 2017 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately ECO�T - - - LOoC AVOonNS = - -OF SEPTIC COMPONENTS LEACHING GALLERY -DISTANCES IN DECIMAL FEET A 8 1500 GALLON SEPTIC TANK I DISTRIBUTION BOX 1 29 25 2 40 18 3 44 29.5 A B DINING BATH BED ROOM KITCHEN ROOM THIS SKETCH IS BED LIVING BED BEST VIEWED IN ROOM ROOM ROOM COLOR FORMAT Q GD�TFC W o NOT ? TOLLJ 4� SCALE L irS 508 364-0894 t5ins.doc-rev.6/16 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 c�M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is Hyannis MA 02601 February 6 2017 required for every y rY 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: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Town of Barnstable GIS maps You must describe how you established the high ground water elevation: Town of Barnstable GIS maps indicate that the property is over 12 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 7 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments ^M 100 Straightway Assessor's Map: 268 Parcel: 110 Property Address Emma M. Alley Owner Owner's Name information is required for every Hyannis MA 02601 February 6, 2017 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE t +� BOTTOM OF N LEACHING GALLERY LEACHING IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i ot� LETTER bF AFFIDAVIT Miy name is Emma'M.Alloy,and 1 am the o wner of my homelocated at 100 Stra ghtway,,Hyannis,MA: I purchased mythree bedroom,orie bath borne in 1966;:and I have been the only.owrner'ofthis'house fo.r 31 InAhe:year 2000,:I paid someone to handle a repair and Title.5 confirmation of my septic system. This.man was recommended by'the Town ofsBarnstable:at thi?;time of theservice.and he handled the As-built filing:with the Board.o.Health, This filing was'Sewage'#2000-091.. On this document that:he filed (w.hich l did not personally sign off on), he inadvertently said A fat my home'was::a two bedroom house. This was in error. The system tivas built,and recently;conficmecl by an inspector,to handle'the capacity of my three bedroom:home,as bt ilt:in 1966. This is�a:three bedr.00.m:home and:always::has been since.l.purchased,it. ]:have been taxed:on a,three bedroom home since:1966: I am happy to have:my-granddaughter: Tanya.Hindle,;or>,my..grandson, Bill Hutciiinson,.open.the house:ao allow. entry for.'anyone:to verify.:It is easy to see,as the original hardwood flooring is still in the living room and;all three; bedrooms: sincerely, Emma.M.Alley STATE OF :IDAHO } )SS: GOUNTYOF. BONNER ) on this: Sth: ;day of. February ,,2012 before me,a Notary Public in and for said,state,. personally a ppeared`.Emma Nl.Alley known or,1dentified:to ine to be the person(s)whose name(s)''is/are subscribed to the within instrument and acknowledged to me that:he.executed the same. 1s 4e+ITNE55 WHEREOF 1 have herequnto set:my hand and of#fixed my official seal.the day and year fir a written: G ti5, Notary Public:for tate,o da#o ` ««,«« .«««• m� NOTARY a Residing at: Sandpoint « n Con?n?issinn Expirt's< 1 I126121 ;PUBLIC JI O , �® 1 �` TOWN OF BARNSTABLE ., LOCATION _ C `� �� SEWAGE VELLAGE-- 44 VZ4—A)Q11 �_ASSESSOR'S MAP & LOT !!1 INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY 11 L 6CX7 G c— LEACHING FACILITY: (t),pe) ao tt�c (size) NO. OF BEDROOMS BUILDER OR OWNER 1i`nrn� PERMITDATE: �OOC7 COMPLIANCE DATE: d Separation Distance Between the: Maximum Adjusted Groundwater.'able 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 ai beN: - �5 Com anwealth of Massachusetts a(o8— I10 Title 5 Official inspection For r, r uyl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address ---- ---------- ----- ----- --- - --- KEVIN CARR 101 CHESTER RD BLANDFORD MA 01008 , Owner — - --- Owner's Name/ information is required for every HYANNIS ✓ MA 02601 6/3/2021 _ _...__..--_---------...-- -- -- ---------------------_ ___ ------ -- -------......------- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information $ � on the computer. use only the tab Trevor Kellett --...--- —--- --- -...--- ---- ----------............ — - -------- -...—--...- ----- ------ key to move your Name of Inspector - -- cursor-do not Cape Cod Se tic Services use the return -... -------p----- - -- —-- ---------- - — ------- key. Company Name j- 350 Main St. ,de Company Address --— W Yarmouth MA 02673 _ 'City,/town State ZipCode SI-13744 508 775 2825 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/9/2021 Inspector`s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate Y p regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform " in the future under the same or different conditions of use. t5insp.doc•rev 7/2 612 01 8 Title 5-Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts 1�= �P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 100 STRAIGHTWAY — --- ---- -- —_ Property Address — KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information i e HYANNIS MA 02601 6/3/2021 requiredfor very -------.__...------- .-.._._..._-------...---------...._...._..- -._..---- --___---------- ------------- --- page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp doc•rev 7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 11 == r `title 5 Official Inspection Form l`, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN_C_ARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name -- ---- — - — -- — — information is HYANNIS MA 02601 6/3/2021 required for every ---------------------- ---...-- ----- -- --------- --- -- --- --- page. City/Town State Zip Code Date of Inspecti—on C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5msp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title Official Inspection Form �:T I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is HYANNIS MA 02601 6/3/2021 required for every -------------------____ _....------------------_ ---..---_ ---------- ---- --- page. City/Town State Zip Code Date of Inspection C. Inspection,Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: -__.....----------------- .__..... -- -- - --------- ---_ ._.....------ ------- -_ 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or - clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 100 STRAIGHTWAY Property Address Owner Owner's Name information is required for every 02601 6/3/2021 page, City/Town State Zip Code Date of lnspe—c C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Z Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El N Any portion of the SAS, cesspool or privy is below high ground water elevation. El Z Any portion of cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply. El z Any portion of a cesspool or privy is within a Zone 1 of a public water supply El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Z 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 iaa cesspool serving a facility with a design flow of2OOOgpd' 10.000gpd. F� �� The oyotonnfgUn. | have Uo��rminedthat one or more of the above failure | �� �� criteria exist as described in 310 CW1R � 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will ba necessary to correct the failure. . 5) Large Systems: Tobe considered a large system the system must serve a facility with a design flow mf10'0UOgpdtn15'OOOQpd� � ` � For large sysbams, you must indicate either"yes" or"no" to each of the fo|lowing, in addition to the questions in Section CA. / Yes No � 0 El the system is within 4OO feet nfo surface drinking water supply Commonwealth of Massachusetts ft Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is required for every HYANNIS MA 02601 6/3/2021 -------- --------- -.._.._.....- _..__.... -— ------ - - - --- --- ------ ---- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ❑ Purnping 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)] 15insp.doc•rev 7i2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments X. -t - T 100 STRAIGHTWAY yr Property Address — --.— ------- ----------- - KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is required for every HYANNIS _-. . _ MA._._- 02601 6/3/2021 page, City/Town State Zip Code Date of Inspection D. System Information 1. 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 _ Description: Number of current residents: -- Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: ------ Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '20 - 32 GPD g ( y g (gp )) '19 - 55 GPD Detail: -- Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Ir Title Official InspectionForm' i `,I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name ---- ------ — -- information is HYANNIS MA 02601 6/3/2021 required for every ---- --...------- ----_ _ _-______--------------- ------- ----...---------- - — page. City/Town State Zip Code Date of Inspection De System Ontc+Irmation (coot.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- --------- -- -- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: --- -- - -- Last date of occupancy/use: fete - - Other (describe below): 3. Pumping Records: Source of information: ----------------------------------------�._-- —___.-- Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons - - — How was quantity pumped determined? - ----- ---- ----- - Reason for pumping: ----- -- - --- ----- ----- - -- t5insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts .JJ ;$ Title ill Inspection For i. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 100 STRAIGHTWAY Property Address K_EVIN_CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name ------ — --- --------- -- --- — — — -- requiredonis HYANNIS MA 02601 6/3/2021 required for every ----------------- - -- ----..._ - ---- ------- -- ---- — --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2000 PER BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 3011feet 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.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.712612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ;1 Title 5 Official Ins coo r i M, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner am Owner she -_ ___.._---- -.----__.- -- information is required for every HYANNIS MA 02601 6/3/2021- _.__..- ---------._.._.._- ---__-._..---------- --.....---- -- ----- -------___- ---- --- - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24 ------ ----- feet Material of construction: FJ 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: 1500 GALLON-- - -- Sludge depth: -- - ------ — Distance from top of sludge to bottom of outlet tee or baffle - ---- -— - - 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 --------- How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subswfiace Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY__ _ _ Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is HYANNIS MA 02601 6/3/2021 required for every --: -- __ ---------__------ _ -- --- --,..__----- -------_....-- - ---- --------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: -------- --- --- feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: --- ------------- Scum thickness ---------- - -- --- Distance from top of scum to top of outlet tee or baffle -- ----------- --- - -- Distance from bottom of scum to bottom of outlet tee or baffle - - ---- - Date of last pumping: Date_..--...__.---------- —_—.- -- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - ----- ---- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: —- --------- -- - Capacity: --- ------_.....- - -- gallons — Design Flow: _... ----- ---- -- -- — --- gallons per day t5insp doc•rev 712%3/2018 Title 5 Official inspection Forriv Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts . i Title l Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is HYANNIS MA 02601 6/3/2021 required for every --...__.....-- .--....... -... -.._........._.._..._._.. - -- -- ---...- ---- -------------- - page. City/Town . State Zip Code Date of Inspection D. System Information (cost.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: -- - -------- Alarm in working order: ❑ Yes ❑ No Date of last pumping: ---- — — ._.._.._..------------------------ Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT tbinsp.doc•rev 7/25I2018 Title f:.Official Inspection Form:Subs,uface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts r, Title 5 Official Inspection Form JI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY = - - -........- -_.._... _. .- . _..---- -- . - --- - -------------- --- - Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is HYANNIS re MA 02601 6/3/2021 _required for every -...__.._.._____._---_....-_--___._.__ __----..--------__-_--_-__-- _ Pa ge, City/Town State Zip Code Date of Inspection Do System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):. * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i Type: ❑ leaching pits number: -- --- -- ® leaching chambers number: 4- INFILTRATORS ❑ leaching galleries number: -- ❑ leaching trenches number, length: --- ❑ leaching fields number, dimensions: --- -- ❑ overflow cesspool number: ----------- ❑ innovative/alternative system Type/name of technology: -- ------ -- — t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner Owner's Name information is HYANNIS MA 02601 6/3/2021 required for every --..... — ---- ------ ---- --_--. ---- _... ---._.._.. - — 0 — —._ page. City/Town State Zip Code Date of Inspection D. System_Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4-INFILTRATORS H-20 RATED FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ------ -=---- --------- --- Depth —top of liquid to inlet invert ---- ---— — Depth of solids layer ------ — Depth of scum layer -- -- Dimensions of cesspool — ----------- - Materials of construction ------ -- --------- Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts 'itle 5 Official Inspection Form --, i.,f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address — KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 - Owner -------------.__. - -----— ---- — ---------- Owner's Name information is HYANNIS MA 02601 6/3/2021 required for every _-- --- -- ---- -..__------- ..- — - --.—.—_..--- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp doc•rev 7I26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•,Page 15 of 18 Commonwealth of Massachusetts ;: ;p TitUe 5 Official Inspection Form mom, ,} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 ------- -------- - ---------- —------ -------------- - - - Owner Owner's Name information is HYANNIS required for every 67 ---_._-- . ..._._. __. MA - 02601 6/3/2021 a e. it /Town - --- --- --- p g Y State Zip Code Date of Inspection D. System anteimatuon (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4o I_ a� i l5usp aoc•rev 7;2012018 Title s official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts - � Title Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER.RD BLANDFORD MA 01008 --- ....-Na'_m__e---- _ _ ... ---------- -._.. - - - ------ --------- Owner Owner's am --- -- information is HYANNIS required for every -- MA-- 02601 6/3/2021 _ page. City/Town State Zip Code Date of Inspection i D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells Estimated depth to high ground water: +11' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: -- - ---- ------ ----- --------. --- Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: HAND AUGER 5' PAST BOTTOM OF SAS WITH. NO GROUNDWATER ENCOUNTERED. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51nsp doc•rev 7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts A� ` RIe 5 Official Inspection Form -t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °t�W 100 STRAIGHTWAY Property Address KEVIN CARR - 101 CHESTER RD BLANDFORD MA 01008 Owner — ------___._. - — -- Owner's Name -- ---- --------- --- information is HYANNIS MA 02601 6/3/2021 required for every _._._._._- ._..__ .. _. _ --------_-_... 1 — - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i iSinsp.Uec•rev 7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map aL Parcel Permit#! ' • Health Division Date Issued q Conservation Division Fee ' e-'Tax Coll 4.--Treasu Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address e) ! G Hryy P N Village ANiyi s Owner l=/� /j'1, / L�y Address %a a 7w,(4 A(T w,/4- -� Telephone o7 2_-r- ;-I 3 ,p Permit Request_ � p�.�n_ A/6 i/ kV1 V A n JY Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost a5-v o Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure S 14 Historic House: ❑Yes ONo On Old King's Highway: ❑Yes No Basement Type: A Full ❑Crawl ❑Walkout ❑Other i Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing ! new Half:existing new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new First Floor Room Count 1 I, Heat Type and Fuel: �J Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing X New Existing wood/coal stove: ❑Yes ❑No i Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size i Attached garage:❑existing ❑new size Shed:4 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name._ 0 w i//e- Telephone Number .fb - 7 Address_ /od -S-r4A j T if r wr+N License# �y aNNI 5 U 6 d 1 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE '�J DATE __ 7 L4Z�,