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HomeMy WebLinkAbout0147 STRAIGHTWAY - Health 147 Straightway Hyannis P r A = 268 217 F z U M� f r Z 7 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way n Property Address Shea Owner Owner's Name Q'I E' information is H annis ✓ MA 02601 06/02/2015 required for every y -M c page. City/Town State Zip Code Date of Inspection , y Inspection results must be submitted on this form. Inspection forms may not be altered in any X way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, p I use only the tab 1: Ins ector: key to move your 10927 cursor-do not A.Riker use the return Name of Inspector Y R.L.C. ratr Company Name , PO Box 726 Company Address fe>� South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 S14590 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 06/02/2015 Ins or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I UI U t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Inspection of Septic tank , distribution box and soils above leach facility were inspected and no obvious failures observed. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): s d. 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•3113 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 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria'are triggered.A copy of the analysis and chain of custody must be attached to this form.] f ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0- Does residence have a garbage grinder? ❑ tYes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2013= 224.4 gal. 2014= 374 gal. Detail: Water dept said the reading were very low.House was a foreclosure and vacant for some time . Sump pump? ❑ Yes ® No Last date of occupancy: uknown/ foreclosure Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: not avalible Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous,inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 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: Installed in 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water supply feet Comments (on condition of joints, venting, evidence of leakage, etc.): Dry with no evidence of backup or leakage Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) 1500 gallon Poly Tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11'6"x5'x6' Sludge depth: 16" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is Hyannis MA 02601 06/02/2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank did have some minor distortion on covers .Inlet and outlet had PVC Teeys that were observed to be at correct heights related to each other. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 147 Straight Way Property Address Shea Owner Owner's Name information is Hyannis MA 02601 06/02/2015 required for every y page. CityTTown 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 equal to 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 obvious carry over observed and concrete did not appear to be cracked or leaking. Riser was added . 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® Teaching chambers number: 4z infiltrators 26'x11'x2' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above S.A.S. were dry and free from discoloration,odor or presence of effluent. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is Hyannis MA 02601 06/02/2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Ke44 LIJ A�I= aeloG ,r �c � h� k •a = j t5ins•3/13 Titfe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/02/2015 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: 9.6 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: file on record ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: f You must describe how you established the high ground water elevation: hand augur within 20' of S.A.S. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ° <LN,\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is Hyannis MA 02601 06/02/2015 required for every H y � page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i a t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 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. C7 N Important:When A General Information fillingng outout forms A.orms ✓/ �. � �on the computer, /I -ze use only the tab f r O 1. Inspector: key to move your cursor-do not A.Riker 'o " e the return Name of Inspector key. R.L.C. Company Name PO Box 726 COIkAf rtv Company Address r South Yarmouth MA 02664 City/Town State Zip Code sl 508-776-6460 S14590 Telephone Number License Number t,. B. Certification certify that I have personally inspected the sewage disposal system at this d dress and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 06/10/2014 fffg—pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under - the same or different conditions of use. 7AV/Jq t5ins-3/13 Titfe 5 Official Inspection FormL41u?cesewa ge Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Inspection of Septic tank , distribution box and soils above leach facility were inspected and no obvious failures observed. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The . P P 9 Y 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GAr ,a''y 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within - 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ z 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 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 t information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information - Residential Flow Conditions: - Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: - Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013= /iSV 17 9 ( Y 9 (gpd)) "2012= '71 G P� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: uknown/ foreclosure Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every y H annis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: not avalible Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Savage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 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: Installed in 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water supply feet Comments (on condition of joints, venting, evidence of leakage, etc.): Dry with no evidence of backup or leakage Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) 1500 gallon Poly Tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1 VT x5'x6' Sludge depth: 16" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2n Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank did have some minor distortion on covers .Inlet and outlet had PVC Teeys that were observed to be at correct heights related to each other. 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-3113 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 w 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 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 equal to 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 obvious carry over observed and concrete did not appear to be cracked or leaking. Riser was added . Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* r Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 • <fCommonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4x infiltrators 26 x11 x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above S.A.S. were dry and free from discoloration,odor or presence of effluent. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction` Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14,of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t9.S-a 31V 1 levy- 76 r u -o t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 10.6 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: file on record ❑ Checked with local excavators, installers- (attach documentation Accessed USGS database- explain: You must describe how you established the high ground water elevation: hand augur within 20'of S.A.S. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Straight Way Property Address Shea Owner Owner's Name information is required for every Hyannis MA 02601 06/10/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS a a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION MAR PARCEL • �—I LOX _ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 147 Straightway Hyannis MA RECEIVED Owner's Name: Ronald Sankus Owner's Address: 90 Kingman Street Lakeville MA 02347 S E P 0 5 2003 Date of Inspection: August 14,2003 TOWN OF BARNSTABLE Name of Inspector: PATRICK M.O'CONNELL HEALTH DEPT, Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 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 Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: -A&—AlDate: ` (� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: System in good condition. ****This report only describes conditions at the time of inspection and under the conditions of use at tha t time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete_all of Section D A. System Passes: _XX_ 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 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 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 fait 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 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: Page 4 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August.14,2003 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 ondin of effluent to the g P g surface of the ground or surface— — — g waters due to an overloaded r 0 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 %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 —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 1 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.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 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 _ — the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply — — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. A Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 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? — _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_ V 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 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 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: 0 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): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)):6750 gals. For two years=9 gpd. Sump pump(yes or no): No Last date of occupancy: Seasonal COMMERCIAL/INDUSTRIAL 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: Tank has never been pumped Source of information: Homeowner 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 _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): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/14/97 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 BUILDING SEWER: X (locate on site plan) Depth below grade: 3' Materials of construction:_cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: I Material of construction: concrete_metal fiberglass_X—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: 1500 Gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid level at bottom of outlet invert Tees are intact and clear. GREASE TRAP: No (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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 TIGHT or HOLDING TANK: No (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: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box set level,no high stains or solids carryover. PUMP CHAMBER: No (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Four Hi-Capacity Infiltrators leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): No excessive vegetation or oonding. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of inspection: August 14,2003 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. �S Za Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Straightway,Hyannis Owner: Ronald Sankus Date of Inspection: August 14,2003 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than l5 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: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS Hyannis quad and GIS. You must describe how you established the high ground water elevation: Groundwater contour map shows water at el. 15 and USGS topo map shows land elevation above el.30. TOWN OF BARNSTABLE r SEWAGE # LOCATION !V 97 6 Z � v ASSESSOR'S MAP &LOT VILLAGE ;INSTALLER'S NAME&PHONE NO. .SEPTIC TANK CAPACITY L (size) �- tEACHING FACILITY: (type) NO.OF BEDROOMS 3 O BUILDER OR OWNER PERMTTDATE: /n .. I h q l COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of teaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet I. within 300 feet of leaching facility) Furnished by q. zS EEL o l� TOWN OF BARNSTABLE ® c J LOCAT`iON 1 S 1 S SEWAGE # 5 JZ R VILLAGE n ASSESSOR'S MAP & LOT — . INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY e a�� LEACHING FACMITY: (type) LA A,L- L (size)-,ILQ�5 I1 krQ NO.OF BEDROOMS _ BUILDER OR OWNER 0 GL v. PERMII`DATE: lO- 1 b- 4—COMPLIANCE DATE: lC-> 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.Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9 �. ti w o� J ia a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PU$LId HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS App acation for Xh5poe;ar *p5tem Construction Perron Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) El Complete System El Individual Components 10 Location Address or Lot No. 1 y-7 Z5TT 1 Owner's Name,Address and Tel.No. -�ca c.,.h a 6 Assessor's Map/Parcel rL (p 8 /L r Q v GG Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -77F-06 R Al Type of ding: Dwelling No.of Bedrooms 052, Lot Size sq. ft. Garbage Grinder( ) Other Type of Building& c� A No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 7330 gallons per day. Calculated daily flow 3 q9 gallons. Plan Date Number of sheets Revision Date Title ►o U C C Size of Septic Tank I S� nn Type of S.A.S. �n Ctu�iTc� ��—� 'ttsfLs Description of Soil SM rP' Nature of Repairs or Alterations(Answer when applicable) _"may ) 5T1A` o W �fA�► ✓�I��1 1 TIA �� juT vr.Tr 2 L,..\ y t �Y Utr2 olti Si toe S 14 u L.,P a—0� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has Signed Date /0-/0%7 Application Approved by Date 10 /OAF 7 Application Disapproved for the f owin reasons Permit No. � S 7&- Date Issued _ ————————————————————----- . ———————————————— .. ....�,..,- _. tt ,.vµ.,...,.,. ...rr a,.:..f..e_ ...: ."t ,..�.;... ,. •ram., - � .. a _. _ __ _ _ _.. r --- No. Fee�..J�'� •--- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . t y t PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS es �l attatton for Mtogoal *pgtem Construction Vermtt Application for, Permit to Construct( )Repair(114upgrade( )Abandon( ) ❑Complete System ❑Individual Components,. .. o Location Address.or Lot No. I Ll 7 Jtv Lx o-1) Owner's Name,Address and Tel.No. /_ j4� S VcG1 " Assessor's Map/Parcel 2 W 8 L Installer's Name,Address,arld.Tel.Vo, Designer's Name,Address and Tel.No. \-\-\ � a", ep-T`G Type of Budding: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building 4 t No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 0 gallons per day. Calculated daily flow 3 4q gallons. Plan Date Number of sheets Revision Date Title U C C � Size of Septic Tank` Type of S.A.S. V— "`Description of Soil S�''� tf'`r` Nature of Repairs or Alterations(Answer when applicable) kJCa 5t4« y T�A- '�— r✓.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 provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance hasbeerr-issneti-b Signed r Date Application Approved by Date /0 /0 Application Disapproved for the f owing reasons Permit No. 5 78' Date Issued THE COMMONWEALTH OF MASSACHUSETTS �• BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that t e On-site Sege D�sgsal System Constructed( )Repaired ( )Upgraded(✓) Abandoned( )by �" i� f �C at y S} r 4` a c-r►� S has been constructed in accordance with the provisions of Title 5 a the for Disposal Sys m Construction Permit No. �.�2P dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date _1 C1 Inspector ' — ——————————————————————--—————————— _ ds. No. Fee,,J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgpogaf *pgtem Conttructton Vermtt Permission is hereby ranted to Construct( )Re air( �pgrade( )Abandon( ) System located at 111 S+rA( P W C t4 c.k-Ny)'�5 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: Approved by CERTIFICATION OF SKETCII AND APPLICATION FOR A DISPOSAL WORKS CONS7'ItUCTION PEItM1T(W.1111OU'I'DESIGNED PLANS) f hereby certify that the application for disposal works construction permit signed by me dated 10 -14-"7) , concerning the property located at L1 7 STV-4h 4zr meets all of the following criteria: /* There are no wetlands within 300 feet of the proposed septic system V• There are no private wells within 150 feet of the proposed septic system V• The observed groundwater table is 14 feet or greater below the bottom of the leaching fAcility • There is no increase in flow and/or change in use proposed dThere are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). 5 O