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HomeMy WebLinkAbout0207 STRAIGHTWAY - Health twa 268-223 Hyannis r a t i j n 1 O ti Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address 1 • Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 ' page. City/Town State Zip Code Date of Inspection 1++ Inspection results must be submitted on this form. Inspection forms may not be altered Any way. Please see completeness checklist at the end of the form. Important:When filling outforms `j A. General Information 4 I aLo 1 f out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return key. Name of Inspector Cape Cod Septic Services r� Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 9/25/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Go* VS Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owners Name information is required for every Hyannis MA 02601 9/21/2017 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: System in working condition. 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 h W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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): y, ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts M w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •" 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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 Commonwealth of Massachusetts H - W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 - 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: ❑ ® 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.] ❑ (g 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 r the system is located in a nitrogen sensitive area (Interim Wellhead Protection El ElArea—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y "p 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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: NumbWof bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °'•t 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is Y required for every Hyannis MA 02601 9/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available usage last 2 ears 2015=39gpd ( Y g (gpd))' 2016=21gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every �H annis MA 02601 9/21/2017 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: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 7 Type of System: ® Septic tank, distribution box, soil absorption system El '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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Approximate age of all components, date installed (if known)and source of information: 1996 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1211 Depth below grade: feet Material of construction; ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 2" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) if tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500Gal Dimensions: Sludge depth: 6-8" l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 - page. Citylrown 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 Scum thickness 3-4" 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.): 1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 2" below grade. Recommend service of tank. 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w •'p 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address Bonnie.Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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 Oil 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 10" below. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil.Absorption System (SAS) (locate on site plan, excavation not required): If,SAS not located, explain why: . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts q W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis annis MA 02601 9/21/2017. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Cultecs ❑ 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.): 3-Cultec units with stone. Units found with only damp soil at time of inspection. No sign of overloading or hydraulic failure. 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•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 C Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name Information is H annis MA 02601 9/21/2017 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.): 9 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'�� 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 — 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 I �I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 207 Straightway Property Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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: +10'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: 1996 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: i You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straightway Property.Address Bonnie Irzyk Owner Owner's Name information is required for every Hyannis MA 02601 9/21/2017 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 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a aUUVUUlll�.,�-a.iullt ..cuu� - Page 1 of 2 AVVY1V VrDluulaItwLD LOCATION j80 7 S'7'i�g/&/0'/A'kd Y SEWAGE N VILLAOE /74)4�&gf er ASSESSOR'S MAP&LOT 8^Z23 INSTALLER'S NAME&PHONE NO.,#P/-V,E .PO 4.-�bs rN-7 7 r=8 77t SEPTIC TANK CAPACITY 4 sn= LEACHING FACILM:(type) NO.OFBEDRUOMS •3 BUILDER OROWNER�,/- fit_ 14i11S ��/�A T Si T' PERMITDATE: �� _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well 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 Ing acility) Feet Furnished by 7� d't7% ��:6V oC iu n `ya a .t`1 0 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=268223&seq=1 9/15/2017 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned Ix)by at po-7 S''7/1AtC ' �� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoL7O I Z /o'j dated hc'lea !Z Installer Designer #bedrooms Approved design flow god The issuance of this permit hall pot be construed as a guarantee that the system signed. Date � /' Inspec r �— ---- ------------------------------ ---------- No.lc) 12— 1 0 -3 Fee ��y 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYltatlon for Vsposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel X7 S72A16H-74/R 40 703 41 8 Installer's Name,Address,and Tel.No.14Yet NNI S Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size G sq.ft. Garbage Grinder( ) Other Type of Building C[f— No.of Persons Showers(`) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board of Health. Date Application Approved by '24 Date �{(Zo Z�tZ Application Disapproved Date for the following reasons Permit No. Date Issued — - ----- ---------------- No. J Fee 2 t7 ou r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: '' ."' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Disposal 6pstem Construrtion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X ❑Complete System ❑Individual Components i Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel 67 s7/2AlGH-74/,q � ) � 491) 7S3 y o` I o Installer's Name,Address,and Tel.No.14YA,vA/1 S I M/T- Designer's Name,Address,and Tel.No. � 5 Type of Building: Dwelling No.of Bedrooms ,3 Lot Size 7(>, (,�[�sq.ft. Garbage Grinder-, ) Other Type of Building �.y-Nc — No.of Persons Showers Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date J . Number of sheets Revision Date Title t,l .- Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore `described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' Date Application Approved by Date (2,0 2 v t Z Application Disapproved . &Date for the following reasons Permit No. Date Issued - 7,7 - - --- - -- - -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS NCertffirate of Compliante THIS IS TO CERTIFY,'that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned' by at ��"7 7Y1AIG •t,��q•J r��l� p�!✓/� ----_-has been constructed-iri accordance / with the provisions of Title 5 and the for Disposal System Construction Permit NoZO I Z Jo 3 dated I4Zo !Z Installer. Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wall-function-as}-designed. Date /� Inspec t�rr � J�--- .•.. -® � k, _ - ---- ----------------------- ----- _ —-- ----- No. U AO 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS M1sposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( System located at ;-J f' MA/G 1J'Z-/wj,41 I yi4 W A11 S , t�� and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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.pe Date Z.i? Approved by - 1� ` Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .9-D7 57X,0l4,1> /?P*,/ Property Address 5r1f&bl>•UG �.�,f , .3—t3/�1Srd c Da, Fa sroIV ,��ss'. a��sZ Owner Owner's Name ' information is r / required for , Y/rsrci�s �ir.S.S• d.gGD� ���9f f� every 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 A. General Information forms the computer, r, use 1. Inspector: �� b only-the tab key to move your cursor-do not use the return Name of Inspector key. TONy C-#OewIS�/�il��s Company Name Company Address ` /'�I.LYs�itw. iy.�ss 02oy s' L" City/Town State Zip Code Telephone Number License Number u (9 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 ❑ Falls;•-? �-•va� F,.« ... :. 4� ❑ .Needs Further Evaluation by the Local Approving Authority "3 ' Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Boa�rd- of Health or DEP)`within 30 days of completing this inspection. If the system is a shared sys*m 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. Vv U /I t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewace Disposal S tem•Page 1 of 17 F Commonwealth of Massachusetts W !Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G„M SOT Property Address Owner Owner's Name information is required for Iwo.wo. d 2 Go/ ili9111 every page. CitylTown 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 :.MR 15.304 exist. Any failure criteria not evaluated are . indicated below. Comments: B) System Conditionally Passes: fit,/4 ❑ 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i— Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for G every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 104 B) System Conditionally.Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 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 s 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 pLblic 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 ❑ ry Backup of sewage into facility or system component due to overloaded or clogged SAS :)r cesspool ❑ n Discharge or ponding of effluent to the surface of the ground or surface waters due to an overlcaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑N� Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-11h0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,•Page 4 of 17 ii Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /l Owner Owner's Name information is required for Y/�/UyIS AAFS� every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Yes No E n Required pumping more than 4 times in the last year NOT due to clogged or `"� obstructed pipe(s). Number of times pumped: ❑ S] 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 El ❑ /S/4 tributary to a surface water supply. ❑ ❑ #,4 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ NA Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ NIA Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility.with. a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El 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•1 Ill 0 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 �0 7 7' Ai.f V Property Address Owner Owner's Name information is required fory /y'`��S /yJ�• O G �4�// every 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 14 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ T Were any of the system components pumped out in the previous two weeks? CVWAIPv,9�.o 3 40 er e-46 gar ) ❑ ® Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently o-as part of this inspection? IN ❑ 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 informat*on. For example, a plan at the Board of Health. 09 ❑ 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): 33� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins 11/10 Titie 5 Official Inspection Forth:Subsurface Sewage Disposal Systerr•Page 6 of 1 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for „ every page. City/Town State Zip Code Date of Inspection D. System Information Description: /V X Number of current residents: Does residence have a garbage grinder?. ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ❑ No NA Seasonal use? ❑ Yes ® No Water meter readings,.if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes [3 No Last date of occupancy: 1��? O c G 4(/&o Date Commercial/Industrial Flow Conditions: NA 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments b -, 0267 Srn,9i6,vr�•�'�' Property Address Owner Owner's Name information is /��N�J S /�/�ss• 02G by //9/!/ required for every page. City/Town State Zip Code Date of Inspection D. System Information (count.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: �u �y� Gy� �' GoCIZG 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 57X X A11 SSG Owner Owner's Name information isy� i5/�/>S /Yd{SS• Q?la�� ��ig�f/ required for every 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: S Y5 rs -111�1 t'/YA& 0 c' a7 j)g co,oy w i 1/2 il74 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: �(] cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well.or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I{ f ,� ►• `Opp t ., '' Septic Tank(locate on site plan): Depth below grade: /V feet Material of construction: concrete. metal fiberglass I❑ ❑ g ❑ 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: Sludge depth: t5ins•11/10 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 bc�M ,fib 7 Property Address Owner Owner's Name information is 1�✓ ?�D� &�/c���� required for /�!� yf-5 /f�if►SS every page. City/Town State Zip Code Date of Inspection D. System Information (cont) Septic Tank (cont.) N0 T'OCGGp Plea Distance from top of sludge to bottom of outlet tee or baffle � aJ�o S.441 t;c 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert., evidence of leakage, etc.): , n FCGoAs¢.�,I/� T/1wk �E�a�pi.a ac'<. �•VfDaT� Ce�oo Nip "I'000wee 1iq�idFi�s �66//�/ir'�s/►� yo/ E Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 9 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name l information isy. .���5 /yi01SS• d-?�d/' S'��9/ I� required for every page. City/Town State Zip Code Date of Inspection D. System. Information (cont.) NX Comments (on pumping recommendations, inlet and.outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /Vb iYF 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -°� ,2D 7 H SV ly Property Address / �5Ti4fiz ,//16 L.L. Owner Owner's Name / information is required for every 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 e �eUfH wp?Iv G�fTLF�'1.c/vF. 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.): �Vnx /S ,( fv F,L 0 r fVP1&,V 1vid jf p 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 12 of 17 -e Commonwealth of Massachusetts W Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required fore/�/S every page. City[Town State Zip Code Date of Inspection Q. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ 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.): u 8 1 ,t ,f t, �d.tir 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 0.17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 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.): Vic 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.): tSins•11/10 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 aO 7 Sr l•�/6 h�7-ZU x Property Address 4 Owner Owner's Name information is S �Xss' required for every 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 t� I l g0 --, �_, Its ��S�eZIl� o '''✓ s��/1� t5i11 s•11110 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 Property Address Owner Owner's Name information is ����s js� to266 �•�l�/�(/ required for /7` every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: © Check Slope © Surface water ❑l Check cellar © Shallow wells Zd 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Fora _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 12 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 o1 17 Your 1 I1 How if-Works It is important to understand how your system works and how this treatment affects it in order to protect your investment. The typical system consists of three (3)main components. The Septic Tank The Distribution Box The Drainfrell The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The Drainfr.eld The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. - How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water camiot drain into the soil, it filters upward causing ponding. foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat, hair, wool, polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box and into the leeching fa- cility, plugging up the stone. Septic tanks should be pumped every two (2) years. C esspooi Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 CMR 15:303. In the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The insp:ctor is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 216 North Main Street Mansfield, MA 02048 Title V Inspections TOWN OF BARNSTABLE LOCATION AO 7 SEWAGE# VILLAGE_ �l�¢iy /� ASSESSOR'S MAP & LOT' �R � INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY • r LEACHING FACILrrY: (type)&/3o.-r NO.OF BEDROOMS BUILDER OR OWNER is PERMITDATE: �/ e COMPLIANCE DATE: Separation Distance Between the: j! Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet �I 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 ofac�h'nq Facility) Feet Furnished by k W C (� Pf C-{ 0 W Si JE, U lT s `J tp . .,. o , i i I Town of Barnstable Regulatory Services Thomas F. Geiler, Director (BARN"T J Public Health Division nttLE. nrn�s. �ip Thomas McKean, Directoo 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 MAIL TO:TOWN OF BARNSTABLE. PUBLIC HEALTH DIVISION 200 MAIN STREET HYANNIS,MA 02601 FAX: 508-790-6304 SEPTIC SYSTEM INSPECTOR REGISTRATION No Fee Charted to Register Date Note: Filing Fee of each report will be: $25.00 per report Name,of DEP Certified Inspector �►/Tl� �'/wa rAwa All G n a Business Address all- rS/b. �.b�11/ S% ��3/✓S/—/�L/rJ', ;t�.�55 'U �ay� Business Telephone No. 1'298' 33q- -1/ T. Caf.2237?sJMA Lic# FAX Number Home Address 2lG .UQ• /y�.csi5.o z�lS' Home Telephone Number The undersigned agrees to comply with PART VIII, SECTION 14.00 of the Board of Health Regulations. `The septic system inspector shall complete every applicable section of the"Title 5 Official Inspection Form-Not For Voluntary Assessments, Subsurface Sewage Disposal System Form," supplied by the Massachusetts Department of Environmental Protection. In addition,at the bottom of the last page of this official inspection form, the septic system inspector shall provide a sketch diagram showing the vertical separation distance between the bottom of the soil absorption system and the groundwater table along with any high groundwater elevation adjustments determined. The Septic System Inspector shall submit a copy of the completed septic system inspection report along with the required processing fee to the Public Health Division Office within 30 days of the inspection date.` S gnature of Applicant Q/healti)"Wpfiles,`sept-insp-ieaisti-ation.doc Hazardous Materials Inventory Sheet Checklist r t/ODate physical Street Address-Check database to ensure it exists L-- -Working Phone Number 77Actual Amounts - ( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) L--Storage Information - location of storage, how long is.storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature.- understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? - provide_a vehicle washing policy and _ xplain it -note that it was given Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's O Main Street, Hyannis, MA 02601 (Town Hall) ffice, 1"FL., 367 DATE: $ /U Fill in please: APPLICANT'S YOUR NAME/S: D Cane " BUSINESS YOUR HOME ADDRESS: n�S M �7.C-�o� n 6 r TELEPHONE # Home Telephone Number. 6�h- - 7 75 _y.2 r z rr � A sa II, NAME"OF CORPORATION: .NAME OF NEW.BUSINESS TYPE OF BUSINESS 1S THIS A HOME OCCUPATION? YES NO C�2b w! I ADDRESS:OF BUSINESS MAP/PARCEL:'NUMBER - (Assessing) When starting a new business there are several things you must do in order to be in compliance with ith the rules and regulations ulatio i Ba ns o rnsts'ble. This for 9 f the To o m is intended f ded to assis t you 'in obtaining t Y g he information you may y need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally o r i m � � OCCUPATION 1. BUILDING COM m gtr6u ' ISSlO ER'S OFFICE RULES AND REGULATIONS. FAILURE TO This individu I h s e n LofTo d a y p rmit requirementsk that pertain to this type of businessCOMPLY MAY RESULT IN FINES. Authsrize� i n e Y COMME TS: �l1 y-_ 2. BOARD OF HEALTH This individual ha be n inforTecdjpf the permit re uirements that pertain to this type of business. if'w��ts NU 01,Tuv.440 &1/I40 MUST COMPLY WITH ALL �� �'E"`!r �j0i��'E• y�� vc--� Authorized nature** �'� �nrE7e uF• L'Anl�li�//GK-La�• COMMENTS: YiAZARDOUS MATERIALS REGULATIONS I` 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) 'F . This individual has been informed of the licensing requirements that pertain to this type of business - ' Authorized Signature** COMMENTS: Date:' TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: /� #83,VNS PG,,A� BUSINESS LOCATION: 207 s'�"a W INVENTORY MAILING ADDRESS: Q NOX U W� ( C'"21 TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: PC, rn t INFORMATION/RECOMMENDA ONS: Fire District: Waste Transportation:In0sf 14 wl N'Vaj)neR Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) ✓Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's aint , varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc, carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) a Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owner's Name information is Y I S ?/�j3 Ma. 02601 5/28/10 required for every Ie �"�OIn lY 0 I page. Cityrrown 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 filling out forms on the computer, I use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key. s ICI Company Name 1 89 Mayflower Lane Company Address : r East Wareham Ma. 02538 -,, Cityrrown State Zip Code— U-) 774-678-9066 S14531 i? Telephone Number License Number a"=- B. Certification I certify that l 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the.DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LA t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 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: i 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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _' ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ ` obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): n 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 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 aseptic 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 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: J 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Cityrrown` State Zip Code Date of Inspection B. Certification (cont:) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any,portion of the SAS, cesspool or privy is below high ground water elevation. E ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® 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 E ❑ 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•09/08 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 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Cityrrown State Zip Code Date of Inspection C. Checklist i Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Forth: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 wM 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump Pum ? ❑ Yes No P Last date of occupancy: current 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 feadings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owners Name information is required for every Barnstable Ma. 02601 5/28/10 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: 1 i owner 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: 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 09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Citylrown State 'Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 1.3' feet Material of construction: ❑cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: +10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): All components were in good condition. Septic Tank' locate on site plan): Depth below grade: 3' . 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: 10.51 x 5.67'W x 5.67'H 21' Sludge depth; t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f J ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Straight Way. Property Address John Delaney Owner Owner's Name ' information is required for every Barnstable Ma. 02601 5/28/10 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 46„ Scum thickness k 911 Distance from top of scum"to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped at this time. - r Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness r , Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date L15,,n". /08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f . f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable, Ma. 02601 5/28/10 page. CityrFown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Orr Depth of liquid level above 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.): I 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: The-soil absorption was not excavated because the septic tank and D-box were functioning correctly. Therefore, the SAS is also functioning correctly:,. t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: } ® leaching chambers number: 3 ❑ 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.): 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 t51ns•091013 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 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 Y r t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE LOCATION AU 7 S?,�g iG�y��� SEWAGE# o!5-, Z t VILLAGE_ //-,y1 y,�/,r� ASSESSOXS MAP&LOT' $_ . INSTALLER'S NAME&PHONE NO. R 4 'e�/ 7 7 $ >'G SEPTIC TANK CAPACITY /6::: LEACHING FACILITY: (type) 1347T Caw, (size) NO.OF BEDROOMS �51 BUILDER OR OWNER 1�l/+ �lgi�J� i /l/A x;S� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet . Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ofUleq C dyngfacility) Feet Furnished by t W I i Q t 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 207 Straight Way Property Address John Delaney Owner Owner's Name information is required for every Barnstable Ma. 02601 5/28/10 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: 20 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 ❑ ry 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: See the groundwater contour map provided. The groundwater contour is 20 going through Straightway. Therefore, the depth to groundwater is approximately 20' in this area. i Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Straight Way Property Address John Delaney Owner Owner's Name ' information is required for every Barnstable Ma. 02601 5/28/10 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 m t5ins•09/09 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17. 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' '( ' } ,a 'Co,itt'to lSsf"iti ..Y..;.t:'�C' Re,.lir...._.. +_,.L.,,t._ Changes saved Request Information Request ID: 21723 Created: 3/31/2008 9:48:05 AM . _ ..___._..................................._......................._...........__._._..__._..._...._....__...._.........._........_..............._............._....._..._...._............_.....__............- .._........_.._.._ Status: Closed Assigned To: O'Connell, Timothy I Health Office Anonymous: No Request Category: Chapter II : Housing Substandard i i Estimated 4/2/2008 Change Estimated Mar APril 2008 May Completion Completion Date: Date: (�io ,. Wed Thu Sri Sat -5 I 6 7 8 9 1 11 .� 20 2.1. 22 2.� 24 ,�5 26 27 28 229 30 1 2 4 r ff6; I 1 8 19 10 Created By: Wadlington, Ellen Priority: Medium E Health Office Citation Numbers: E i _............._.....................__..............._....................................._.....__.._.__......_.............................. ....._..................................._..................................._._...._................._.__._. Requester Information Requestor Gina Rozzitano Request tenant j DETAILS: 207 STRAIGHTWAY LOCATION: 207 STRAIGHTWAY i Hyannis Ma 02601 Hyannis, Ma 02601 774-392-3427 Request Parcel Number " No front railing on steps; front Ma 268 Block: 223 Lot: 000 P .u.� proch light fixture is inoperable; toilet _ will not flush; no storm windows, Parcel Lookup mold in bathroom, no vent; kitchen F floor material is dislodging and no railings going down to basement. Septic is backing up into basement. http://issgl2/intemalwrs/YvRequest.aspx?ID=21723 4/29/2008 �r (mot en Web Request Page 2 of 3 i Email: Track Request Progress Request Work History: Internal Note History: t Entered on 3/31/2008 3:22:50 PM System entry on 3/31/2008 9:48:05 AM: by O'Connell,Timothy ` Assigned to O'Connell,Timothy On 3-31-08 went to said property and talked with tenants son. I left card and told i System entry on 4/29/2008 3:17:31 PM: him to have her call me for an appointment. I Request Closed by oconnelt Entered on 4/1/2008 3:01:02 PM {{ by O'Connell,Timothy I � On 4-1-08 went to said roe and did E property rtY observe large amount of violations. Will prepare order letter ASAP. See below i I Entered on 4/8/2008 3:06:32 PM i by O'Connell,Timothy i Last modified on 4/8/2008 3:10:04 PM f I have been receiving many calls from i tenant who states the landlord is not dealing with problems. Later on same day 4-7-08 owner along with another women came to j E office and stated that tenant will not let him in home to fix problems. I have called tenant and i told her she has to let owner in to make repairs. This has been a hard situation due to fact both parties are blaming each other. The i owner has prepared a notice to vacate and is processes of filing it. He also said he is going to obtain a lawyer to help get into property. I Entered on 4/14/2008 3:19:11 PM i by O'Connell,Timothy Met with owner and tenant at property. Owner was in process of fixing violations. mmry Entered on 4/29/2008 3:17:31 PM by O'Connell, Timothy I have called tenant numerous times to gain access into home due to fact owner has called and stated violations have been correct. Enter work progress: ; Enter internal note: (Viewed by everybody) (Viewed internally only) I http://issgl2/intemalwrs/WRequest.aspx?ID=21723 4/29/2008 Certified Mail#7006 2150 0002 1041 8825 � Er ,Town of Barnstable.' Regulatory Services ASS Thomas F Gei er, Director �^ Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 4, 2008 William Blasetti 11 Island View Drive Hyannis, Ma 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY_ CODE"II =.MINIMUM STANDARDS-OF FITNESS FOR HUMAN HABITATION AND°THE TOWN OF BARNSTABLE"CODE CHAPTER 170. The property owned by you located.at 207 Straightway Road, Hyannis was inspected on April 1, 2008 by Timothy O'Connell,Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received by the Town of Barnstable Health Department. The following violations of the State Sanitary Code were observed: 105 CMR 410.351 - Owner's Installation and Maintenance Responsibilities— Observed that kitchen sink drains were leaking under cabinet. These leaks were also observed leaking into basement through kitchen floor. Also observed within basement that there was standing water which appeared to leaking from hot water heater. Observed that toilet continue to run and toilet does not flush properly. Observed that front porch light blows fuses when turned on. 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements— Observed that kitchen floor was in need of repair due to leaks from kitchen sink. 105 CMR 410.503(A&D) - Protective Railings and Walls—Back deck missing balusters. Observed hand rail leading into basement in need of repair. Q:\Order letters\Housing violations\207 straightwaye.doc The following violation(s) of the Town of Barnstable Code were observed: 1� 70-4- Certificate of Registration—Property is not registered with Town of Barnstable Health Department. You are directed to correct the violations listed above within twenty-four(24) hours of your receipt of this notice by installing balusters on railings of back deck. You are directed to correct the violations listed above within seven (7) days of your receipt of this notice by fixing drains; by repairing flooring within kitchen; by investigating standing water within basement and fixing hot water heater if necessary; by fixing or replacing exterior light in front of home so it does not blow fuses when turned on; by fixing or replacing toilet; by repairing handrail leading -� into basement; by registering with Town Rental Ordinance. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH o s A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Gina Rizzitano Q:\Order letters\Housing violations\207 straightwaye.doc 1` . — z F . , n to Complete items1,,2,and 3 Also complete A Signature item 4 if Restricted Delivery is desired. X ❑Agent o Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery G I o Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes f 1. Article Addressed to: If YES,enter delivery address below: ❑ No / S I �� ,/�, 3. Service Type i - 1 P 1` / ❑certified Mail ❑Express Mail J/ ��pig ❑Registered ❑Return Receipt for Merchandise j ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7 0 0 6 2150 0002 1041 8825 I (Transfer from service label) I `' ty s !+;{•;_ i: i, I f PS Form 3811,February 2111 ;;Domestic Return Receipt 102595-02-M-1540 I \` i( SiSi# i �I 6C-G0-VSGGT-;Zr,G 1-4 G f S -LLlyf` 'ij Li3- .L ednr € 6C on VTW T96 Wti "i�i� o I:.l. SW'l€3 n O ,r 1r A'faCk 0 040 , eS �`•�. V119 3000 dIZ 1NOU-4 G31IVV4 a0ddd 8£Z909t,000 }' S2QQ `Ch0'C 2000 OS22 900E •�+ Y 1• Z o 109ZO VW `stuur/ig q' 036 IaazlS u?gW OOZ ssvw 2 '378tlYSMItlY t: �� ,r<,t= a�s uoisinIG u11B3H 0tignd f f a � i aiqujsuauq jo uejos "�0 3w►i ,a>; f _ _ FORM30 C&W HoBBsBWARRENTM THE COMMONWEALTH.OFMASSACHUSETTS BOARD OF HE H CITYITOWN W ' / PARTMENT t WM Syey`�W ADDRESS TELEPHONE Address (go Occupan Floor Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms — No.dwelling or rooming units N . tories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: 2 \ STRUCTURE EXT. Steps,Stairs, Porches: _ J /1 Dual Egress:and Obst'n.: , ❑ B ❑ F ❑ M Doors,Windows: Roof 3� Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n. Hall, Floor,Wall,Ceilin 10 Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: S 1 PLUMBING: Supply Line: Fr ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents (410 ELECTRICAL Panels, Meters,Cir.: / ❑ 110 ❑ 220 Fusing,Grnd.: — V/ AMP: Gen.Cond. Distrib. Box: A � Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlet5 Walls Ceils. Wind_ Doors Floors Locks Kitchen —M-aA � S®� / Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Buildin Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY INSPECTOR TITLE i A.M. DATE TIME I P.M. t A.M. THE NEXT SCHEDULED REINSPECTION 1^ t P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMF:410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or.other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 1,05 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating,gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ,h FORM30 H&W HOBBSSWARRENTM THE COMMONWEALTH OF MASSACHUSETTS � BOARD OF HE L H CITY TOWN 7�, 1 "'DEPARTMENT 0 ADDRESS 4�M 56 y`0� TELEPHONE { c Address, �0 _ Occupant_. Floor Apartment No. No.of Occupants _ NoofHabitable Rooms No.Sleeping Rooms _ No. dwelling or rooming units_ N . tQries ^, Name and address of owner 1 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: N^4�f Roof 26 t C} ( Gutters, Drains: r i Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin : 'f t410 It &® v Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,'Vents:- - PLUMBING: Supply Line: t L ' ❑ MS ❑ ST ❑ P Waste Line: a- H.W.Tanks Safety and Vents * (410 35 ELECTRICAL Panels, Meters,Cir.: j J / ❑ ❑ 220 Fusing, � �, IAAJ AMP:P: Gen.Cond.nd. Distrib. Box: "� Gen. Basement Wiring: DWELLING UNIT Ventil. L to ; Outlets Walls %Ceils. ,Wind. I Doors Floors Locks Kitchen - f ( 4I0 5:c Bathroom (4IG aV Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten: Gas Oil, Elect.: a Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n:- General Building Posted Locks on Doors: 1 ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY. ' INSPECTOR TITLE A.M. DATE t — TIME ( � P.M. A.M. THE NEXT SCHEDULED REINSPECTION ` / P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in resideitial premises, shall be deemed conditions which may endanger or impair the health,or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation,any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. =ailure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violeticn(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410 180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. D Failure to provide the electrical facilities required .b 105 CMR 410.250 B 410.251 A 410.253 and the lighting in com- mon P q Y ( ). ( ), 9 9 mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disoosal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of i05 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or Spread of disease. (J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulatio-i or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heati-ig system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, ins c.infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. TOWN OF BARNSTABLE LOCATION A 0 7 S72% /&16'�A-L/t Y SEWAGE # VILLAGE /z�4-4t ASSESSOR'S MAP& LOT �°"�4-Y INSTALLER'S NAME&PHONE NO. 0-12 , SEPTIC TANK CAPACITY _ < LEACHING FACILITY: (type) ,6-d® _ /�X"(size) NO.OF BEDROOMS BUILDER OR OWNER' PERMTIDATE: COMPLIANCE DATE:T9�fe� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea ng�acility) Feet Furnished by r H c'1 t3 Q r3 0 A �n )�� 50.00 No. lL� (��-f/ � � see THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for ;Di9;poga1 *p!5tem Cow6truction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) D Complete System ❑Individual Components Location Address or Lot No. 207 Striaghtway Owner's Name,Address and Tel.No. Henry J Williams Hyannis, MA (Tony Nassif— 11 /29/96 ) Assessor'sMap/Parcel y 23 Burwell Rd, W. Roxbury MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr, Septic Srv. P.O. Box 1089 , Centerville, MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(nc) 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 sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Septic system consisting of 1500gal tank,_ d—box, and 3 #330 Stonepacked, Cultex infiltrators. Pump and fill in old cesspools . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' o of Health. ^n Signed Date Y Application Approved by a Date Application Disapproved for the following reasons Permit No. Date Issued L? THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ,PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE} MASSACHUSETTS Zlpplication for Wgpogar bpgtem ctCon!5truction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ElIndividual Components Location Address or Lot No. 207 Str i aghtway Owner's Name,Address and Tel.No. Henry J Williams Assessor'sMaprnazcel Hyannis, MA ( 1 23 Burwell Rd, W. Roxbury MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and eV o. Wm E Robinson Sr, Septic Srv. P.O. Box 1889, , Centerville, MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(nd 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 Hof Soil sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Septic system consisting of 1500gal tank, d-box, and 3 #330 Stonepacked, Cultex 19f iltratorQ Pump and fill j n old loAsspools . f" Date last inspected: { Agreement: ` The undersigned agrees to ensure the construction and-maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o of Health. Signed Date Application Approved by IL e Date II Application Disapproved for the following reasons a Permit No. i $ Date Issued THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS (Massif) Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded Abandoned( )by Wm E Robinson Sr, Septic Srv: at 207 Straightway, Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 07 dated i Installer ft E 1-nobins^n Sy-4 Designer G The issuance of this permit shall riot be construed as a guarantee that the system wt 1 function as designed Date , ". Inspector". " ;- 4 No. � / Fee450.00 THE COMMONWEALTH OF MASSACHUSETTS (Massif) PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal *pgtem Congtruction Permit 1. Permission is hereby granted to Construct(' )Repair( X)Upgrade( )Abandon System located at 207 Straightway, Hyannis. MA By Wm E Rubinson Sr, Septic Srv. 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:Construe ion mu it be completed within three years of the date of ' igss pe it. p. / t, Date: „ Approved by _ J ,� �. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.,hereby certify that the application for disposal works construction permit signed by me dated//-.;21s-9 ,concerning the property located at 207 Straightway,Hyannis , meets all of the,following criteria: * There are no wetlands within 300 feet of the proposed septic system. * There are no private wells within 150 feet of the proposed.septic system. * The obseved 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. * There are no variances requested or needed. SIGNED ATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 4 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). S, r a �. �� r �= 12 Commonwealth of Massachusetts , Executive Office of Environmental Affairs AFC Department of �� � .r � e0 Environmental Protection 1y90 MMIM F.VMd Tnrdy Ooasmor Arplo ftul Wluocl L tL Oorentor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddress: 207 JStrai h4way, HyannisAddress ofl)wner. Tony Nassif Date of I on: `" . / '� If different 23 Burwell Rd. Name of Inspector.. W.E. Robinson SR W Roxbury.,:. MA 02132 Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se disposal systems. The system: _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: ti a Date: //— --9j The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A) 77�PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303., Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indite yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or ezflltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (r 111-/03/95) 1 One VAnter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 is Telephone(617)282-SM ` Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pn*wtyAddress: 207 Straightway, Hyannis, MA Owner. Tony Nassif Dale of Inspsetion: //--OZ9—- B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed,in the distribution boa is due to broken or obstructed pipe(@) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(*)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require Auther evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform 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 b ppm. 8) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 207 Straightway, Hyannis, MA Owner. Tony N ssif Date of Inspection: -- D] . FAIIJ9: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or.surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: 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 Zons 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program requiremsnfi of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for fiuther information., (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST pzepw4yAddj,@m 207 Straightway, Hyannis,. MA Owwr. Tony Nassif Dde of luspeotion: Check if the following have been done: LooPumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --S built plans have been obtained and examined. Note if they are not available with N/A. facility or dwelling was inspected for signs of sewage back-up. uZ'he system does not receive non-sanitary or industrial waste flow tll a site was inspected for signs of breakout. system components,excluding the Soil Absorption System, have been located on the site. I'he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , '7U/f mAHty owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- surface Disposal System. a (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2.07 straightway, Hyannis, MA owner. Tqny Nassif Date of Inspection: FLOW CONDITIONS RESMZNTIAL Design flow:--ij-2—sallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):�/ Laundry connected to system or no):, d 3 Seasonal use(yes or no):Aa v 1 9 9 5 - 6500 cubic feet Water meter readings,if ble: — cubic feet Last date of occupancy:? COMMERCIALIINDUBTRL\L: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING REC�S d source of information: System pt6ped as part of inspection: (yes or no),_ ' If yes,volume pumped: ¢allons Reason for pumping: TYPE O Septic tenkj i ibution box/soil absorption system Single cesspool Overilow cesspool Privy Shared system(yes or no) (if yea,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)/L O (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 Straightway, Hyannis, MA Owner. Tony Nassif Date of Inapeotion: SEPTIC TANK floats on site plain) Depth bey.grads:d ��—metal—FRP Material of construction: —other(explain) Dimensions: Sludge depth. !� a Distance from top of aNdge to bottom of outlet tee or baffle:,L/3 Scum thickness: , 1 Distance ftin top of scum to top of outlet tee or baffle: Distance f em bottom of scum to bottom of outlet tee or baffle: I-4/ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) 4✓ G E TRAP: — (locate n site plan) Depth low grade:- Mate ' of construction:concrete—metal—FRP--other(explain) ns: Scum f9rom top of scum to top of outlet tee or baffle: 11oom bottom of scum to bottom of outlet tee or baffle: Co ( t. n for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evide of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 207 Straightway, Hyannis, MA Owner: Tony Nassif Date of InspeoNon: 1/,Z 9 a 1 77ORT OR HOLDING TANK_ (locate an d plea) Depth below Material of concrete_metal_FRP_other(explain) Dimendons. Capechr. one Design flow: lonoday Alum level: Comments: (condition f inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: D Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) zz — � PUMP BER:_ (locate on plan) Pumps in wor order:(yes or no) Comments: (note condition f pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrem 207 Straightway, Hyannis, MA Owner. Tony Nassif Date of Inspsotion: SOEL ABSORPTION SYSTEM(SAS) (locate an site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be,present,explain: Type: leaching pits,number:_ lsaohing chambers,number: leeching galleries,number: leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of ve tion,etc.)h6 L=L o/ F 40 `- 41 C POOLS:_ j ( on site plan) N and configuration: Depth top of liquid to inlet invert: Depth solids layer. a ✓ Depth scum layer: / of cesspool: Ma of construction: In ks"o of groundwater: (cesspool must be pumped as part of inspection) Comments: note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) PRIVY: (locate on plan) Materials o construction: Dimensions. Depth of so Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) peopertyAddrew 207 Straightway, Hyannis Owner. Tony Nassif Date of Inspection: /l c-Z SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate an Wells within 100, i ,1 '2o '� u 2 DEPTH TO GROUNDWATER Depth to groundwater.14 feet IL(- method of determination or approximation:2b= s r 14c (revised 11/03/95) 9 citizen Web Request Page 1 of 3 Y cy � ,,3�,Ca°x. ✓ as -f . �,_ - '" �✓ day �!gq('d Ci A5: Y Citizen e � � Po� Request Information i Request ID: 21723 Created: 3/31/2008 9:48:05 AM I Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Estimated 4/2/2008 Change Estimated Mar April 2008 May Completion. Completion Date: Date: Sun Mon Tue Wed Thu Fri Sat 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 ...................__.................................._........... Created By: Wadlington, Ellen Priority: Medium edit z Health Office Citation Numbers: edit -77� - Requestor Information Requestor -Gina�Rozzitan Request tenant DETAILS: 207 STRAIGHTWAY LOCATION: 207 STRAIGHTWAY :Hyannis Ma 02601 Hyannis, Ma 02601 E 774-392-3427 � No front railing _ �• Request Parcel Number g on steps; front Map: 268 Block: 223 Lot: 000 proch light fixture is inoperable; toilet j will not flush; no storm windows, Parcel Lookup (.mold in bathroom, no vent; kitchen floor material is dislodging and no railings going down to basement. http://issgl2/IntemalWRS/WRequest.aspx?ID=21723 3/31/2008 r a citizen Web Request Page 2 of 3 Email: Edit._Req uestor.._Information. Trek Request Progress Request Work History: LL Internal Note History: 3 System entry on 3/31/2008 9:48:05 AM: I Assigned to O'Connell,Timothy Enter work progress: Enter internal note: (Viewed by everybody) (Viewed internally only) E SpeII Check 7ZSp IICh`e I Add document or image link: 7 'You cam, type in fi: folder n -ie to everything in the folder Current Links: Time worked on request Response time: Time entries @@ are in qq hours. Examples of time entries; 1�..2�your first, 0,75, 1, `.5� 025, request, 2 ,}0 111 is Response t€itx Measured G3 f£i.%I,i �,i 1d L,f }i„�3f x,.iL to }iJ bff $}B wT i.-actions 11}, the iS.4�iF ,:t�. Do not indudc nights, weelkc ds, )nd haild ys in response time for nt�ost, depart'inents. Save Changes i , Check to notify town employee below to review this request. Save changes and notify - CItIZen* Health Office _ _. __. Close request Barrett Caitlin Brief message to reviewer: C, Close request and notify citizen* http://issgl2/lntemalWRS/WRequest.aspx?ID=21723 3/31/2008 ,a ;citizen Web Request Page 3 of 3 *PSCadfy vvt;,,'ks erClcita add;es5 bvacas giver-, r L fi Update SpeIlCheck,. Public Use: Printer Friendly_Version Internal._Use: Printer Frien.d_.iy.Version http://issq l2/lntemalWRS/WRequest.aspx?ID=21723 3/31/2008 is ' Parcel Detail Page 1 of 3 wV " r n a d er .> 22 Logged In As: u i arcr., Loo 7p Parcel Info _.... .._ _ ...._. __._ ....._ .._... .,. Parcel ID:268-223 Developer LOT 2 Lo Location I207 STRAIGHTWAY Pri Frontage 110 ........__._.. Sec Road 'CANDLEWICK LANE sec `98 Frontage village,HYAN N IS Fire District i HYANN IS _..., .--. .. ......... ---------------- Sewer Acct Road Index:1543 r� lr�" Ma Interactive l/JJ-l p Owner Info _.__.. ................ _ ..._. Owner SHAW NANCY K & Co-Owner BLASETTI, WILLIAM H Streetl 11 ISLAND VIEW DR Street2 . _....... _. City'HYANNIS State MA zip 02601 Country Land Info .. ......... -__ .........__ ....--. __ _ ..._..... Acres 0 23 Use Single Fam MDL 01 zoning RB Nghbd 0107 Topography Level Road Paved Utilities!Public Water,Gas,Septic Location Construction Info _._. _._....... BuildingI of I Year'1972----- Roof'Gable/Hip -__.__ Ext Wood Shingle Built= Struct Wall Effect-µ1'194 `'" "'" Roof Asph/F Gis!Cmp AC None Area Cover Type _ ..... Style=Ra 1.nc 1.h wall;Drywall »»m�, Roomds 3 Bedrooms Model'Residential Int ""''— "" " Batn`2 Full Floor. Rooms _... Heat: _.. _ ...,. Total Grade;Average Minus Hot Air Rooms 5 Rooms Type' http://issql/intranet/propdata/ParcelDetail.aspx?ID=19548 3/31/2008 Parcel Detail Page 2 of 3 Heat . .'. .... Found- Stories i 1 Story Fuel Gas ation Poured Conc.....- ` Permit History (seas data P 1rpose Permit# Amount hasp Date Comments Visit History ..........._... ..._. . Date Who Purpose 2/5/2002 12:00:00 AM Paul Talbot Meas/Listed 9/15/1991 12:00:00 AM ML Sales History ____----_.__._.__.___.._... Line Sale: Date Owner Book!Page Sale 1 1/21/2000 SHAW, NANCY K& 12793/014 2 7/23/1999 SHAW, NANCY K 12430/097 3 12/4/1998 BLASETTI, WILLIAM H 11888/217 4 12/9/1996 NASSIF, FAYEZ 10516/340 5 5/15/1996 WILLIAMS, HENRY J TR& 10208083 6 WILLIAMS, HENRY J 1528/133 - Assessment History _ _.._. .__. ..____ ___ ...__..__ ._._v___.. . _... ____ ____.___._.....____ .__.... _.._-___ ---- Save# Year Sullding Value XF Va6.,ge CAS Value Land,Value Total Parc: 1 2008 $108,700 $2,600 $400 $180,400 3 2007 $108,100 $2,600 $400 $180,400 4 2006 $99,100 $2,600 $400 $181,400 5 2005 $94,200 $2,600 $400 $128,100 6 2004 $76,300 $2,600 $500 $108,900 ; 7 2003 $69,300 $2,600 $500 $41,900 8 2002 $69,300 $2,600 $0 $41,900 9 2001 $69,300 $2,600 $0 $41,900 10 ' 2000 $34,000 $2,300 $0 $27,900 11 1999 $34,000 $2,300 $0 $27,900 12 1998 $34,000 $2,300 $0 $27,900 13 1997 $54,400 $0 $0 $21,700 http://issgl/intranet/propdata/ParcelDetail.aspx?ID=l 9548 3/31/2008 Parcel Detail Page 3 of 3 14 1996 $54,400 $0 $0 $21,700 15 1995 $54,400 $0 $0 $21,700 16 1994 $55,700 $0 $0 $27,900 17 1993 $55,700 $0 $0 $27,900 18 1992 $63,300 $0 $0 $31,100 19 1991 $64,800 $0 $0 $55,900 20 1990 $64,800 $0 $0 $55,900 21 1989 $64,800 $0 $0 $55,900 22 1988 $47,700 $0 $0 $20,000 23 1987 $47,700 $0 $0 $20,000 24 1986 $47,700 $0 $0 $20,000 Photos http://issq l/intranet/propdata/ParcelDetail.aspx?ID=19548 3/31/2008 AGREEMENT TO VACATE PREMISES This Agreement is made this day of February 2008 and is made BETWEEN William Biasetti 11 Island View Road.Hyannis Ma 02601 LANDLORD/OWNER And GINA RIZZITANO 207 STRAIGHTWAY HYANNIS MA 02601 TENANT/OCCUPIER WHEREAS 1 Tenant occupied the rented premises 207 STRAIGHTWAY as Tenant pursuant to a LEASE 2.The LEASE has expired and the LANDLORD is not renewing it 3 TENANT owes more than $5000.00 in rent arrears 4 TENANT agrees to vacate said house on or before March 15,2008 In Consideration of this AGREEMENT 1.Landlord waives all rent arrears 2 .Tenant�waives any rights she may or may not have had against the LANDLORD for any reason This agreement can be incorporated as a judgment in the appropriate Court on the application of either party S NE Wiilia Bla i �� -�T JCC►'YYlG�/ b his isclose get -1((Ji�ZS 31 c�t5 .......................... q J .n F Daley St 31NED GINA RIZZITONI .......................................... NOTARY SEAL PtC?i ,lPl�l ._ �cZ 0 Hd L— ddV BJDZ