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Home My WebLink About0014 UNCLE JOES WAY - Health 14. Uncle Joes Way � Hyannis P A 292 305 1 1 I , e r TOWN OF BARNSTABLE LOCATION1SEWAGE# �VI VILLAGE r I) ASSESSOR'S MAP&PARCEL ' „2 INSTALLER'S ANTE&PHONE NO. 5 C y A T C CANV 0 8r 4��L4 U 0 r. SEPTIC TANK CAPACITY eXr k S 'k W O O LEACHING FACILITY:(type) & "10 �"'�L (size) NO.OF BEDROOMS OWNER S C V4 0 r +'•s•�sr f , PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and.Leaching Facility(If any wetlands exist within 300 feet of leaching,facility) (� Feet FURNISHED BY i t '� w �' '. -�`� � �. �� N� � � �,� �, �� w C �. y rep r L � �..� � �` ', �:� r�� No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4phra.tion for Misposal 6pStem ConstCurtion Vermit Application for a Permit to Construct( ) Repair(i,�j' Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. V,Na,_ _&Oe"S U X Owner's Name,Address,and Tel.No. Assessor's Map/Parcel C LAY G.nn� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.Nqq. Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder([`r) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ''� C) gpd Design flow provided oL4 gpd Plan Date `t o� ' 1--a-1 %g Number of sheets Revision Date Title Size of Septic Tank :C k�s5 `6 ® Type of S.A.S. Gtt- C�k�'U Description of Soil 2L.nc a l i x 2- Nature of Repairs or Alterations(Answer when applicable) ` (.R 2.5([iA—v 15 9,A, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. p Sig d Date 12 113 Ilk Application Approved by Date c� b Application Disapproved by Date for the following reasons Permit No. C40`t '" Date Issued �" s� �V a 1 w No. " y.:;< Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in co puterl..Jl./: f Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS R. 4plication for .Misposaf *pstem Construction Permit Application for a Permit to Construct( ) :i R tr_( Upgrade( ) Abandon( ) ❑Complete System (individual Components Location Address or Lot No. �y nLlt. SC1�S C, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel U f l.v4.M Installer'sly— Name,Address,and Tel. o. Designer's Name,Address,and Tel.No. kl3 Okd yC_r ,%Q h, 2Jy Ty fcoArCctn /S'r&,Cu Re J y tzvS Type of B ilding: g Dwelling No.of Bedrooms Lot Size 04a sq.ft. Garbage Grinder(A Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required) ! 7 gpd Design flow provided '�'� y(f gpd Plan Date Number of sheets Revision Date T Title Size of Septic Tank L , c., r1 Type of S.A.S. SO 0 CI.L,AbW Description of Soil � Nature of Repairs or Alterations(Answer when applicable) n p ��-r�-ate—� �- �—� 4✓. Date last inspected: a 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. Si d Date .2 // Application Approved by pR Date Application Disapproved by Date for the following reasons Permit No r Date Issued3 Ft r THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V.-T Upgraded( ) Abandoned( )by `AL`�! at l t, tr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No p ated Installer c E,,� �r „ Designer �ti F � ..• —�— #bedrooms 'Z Approved design flow ft `� '�o gpd The issuance of this permit hall not be construed as a guarantee that the system will nction as!designed Date l InspectorJ�- �— ---------------------------------------------------------------- ------------------------------------------------------------- No: — �'""` Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS - DisposaC *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(V/ '` Upgrade( ) Abandon( ) System located at �� L�R r t.?c v tit 4f O!N^I K 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 comp eted within three years of the date of this pem rt. Date ► Approved b} 'Fovvn of Barnstable �oF Regulatory Services Richard V.Seali4 nterim Directot� BARNSfABLF. r Public Walth:Division 'ro►u•� ;.Thomas 1lcKean, Director 1-60 Nbin Street,t.kyannis,AIA 0260f Office. 503 SG'?-4644 Fax: 5W700 GaOa Installer&Desigilet Certifica#i m Forth Date: c- 7t26qq Sewatie P.ermit## .� U �(- 3�1 aAssessor's Ivtat)\Parcell ? Desurner: �w,ok nstaller: Sco l� Lr1 T(-w�V(, Add>ress tS> Gee I If i-Y44- . Address; o Oti: \3-�V- was issued apermitto install a (da-tc) //LL (installer) septic system at based on.a desifgn dray+Jn lay (address) .� 1 01 dated vu Zit {designer) I certify that the septic system referenced above was installed sttbstatttially according to the. design, which nay include minor approved changes sudl its lateral relocati n of the distribution box and/or septic tank. Sirip out.(if required) vas ispectedl and the soils were(found.satisfactory. I ucrti f y tlt:at the septic system referenced. above: wars installcd with major changes (i;c. greater than..IO' late al relocation of the SAS or any vertical rclocati:on oFany cti;nponent ofthe septic system) but in accordance with State & Local ltegttlaiidns. Flan revrision car certified as-built by designer to follow, Strip:oui (if required) was inspected rind the soils were iound satisfactory. I certify that:the system referene.ed above VAtas.construc vuctinta e.-with, the tends of the RA approval letters(if applicable) = tt Ei O if (Ins a ter's Signziturc) , (Designer's Signature) (Affix.Designer's Stamp-Here) 'PI.,I ASi✓ I2E' ORiN "ro 13AANI STABLE PUBLIC HEALTH DIVISIC3N. CI 1I'i'IFJCA'1'N. OIL COMPLIANCE '1't'1,1,,. NO'r BE ISSUED UNTIL BOTH "1RIS F0R' A\lll tAS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISTO"N: THANK YOU. :�Set�u rli?esi i�Lt�crtiftetniou Fornt Rev 8-14-13,doe J Town of Barnstable P# a� Departuieut of Regulat:oi-N :Sei--ices Public Health Division Date qD U tqi 654 p� e 260 MainStreet-Hyannis vLA02501 1,,A Date Schedule`cl /Time Fee.Pd. Soil Suitability Assessment for Sptage Disposal. ' Pt Performed B� 1/�LiD7 �f3 '�11 Cl it fN r- Witnessed Bv- LOCATION. GENERAL hiFOR�t1ATON Location Address �C)e G sI�C 5 ) � y Owner's Nan re �(o(v?ti 1 S W ,address d i)a v;4 CL Assessrn.a�iapiParcel: 2 (.Z 3 � �',�</ 4,. fingineer'sDantep� �r /,_ (� '.NEW CONSTRUCTION REPAIR` V Telephone r ``'�a 364 Land Use Rey t m 10i Slope 0/0__v Surface stones oL� Distances from. Open Water Body t o D ft Possible Wet:lea'1�Q/� *f ft Drinking 1k1ater tNV`ell ft Drainage%Vay O_ft Property Line ' V + ft Other ft SKETCH:(Street name,dimensions of lot;exact locations of test holes&perc tasts-locate wetlands in proximih to holes) C a � 6 r f rn GN t4f Parent material(geologic) �� G� CSU 'i.��tS Depth to Bedrock Depth to Groundniater: Standing Water in Hole: ��j�� 7 d Weeping from Pit Face Estimated SeasonaI High Groundwater More-'}- ,9 v 3ETER'Nill'T\�TIO V'F'OR SEASONAL I-IIGH WATER TABLE Method Used- Vh p F' ` (� Depth Observed star dung in obs.hole_ in. Depth to soil mottles:rtD Re- ,qf'- ��O is Depth to weeping from side of obs-hole: in. Grounder ater Adjustment ft_ Index Well= Reading Date: Index Well level Adj.factor- Adj.Groundwater Level_ .., , ' PERCOLATION;TEST. 'vate�2- `t igTrne 4` �'� Observation , Hole= Time at 9�' q r - Depth ofPer-c f Time:at 6: Start Pre-soak Time'? N Time/9 -6';i End Pre-soak q-00 Rate 1Tin.Anch � Site Suitability Assessment: Site Passed Site Failed: Additional Testine'Needed kiiVl y\j - •, i r t r Original: Public Health Division ObseiYation Hole Data To Be`Coinpleted,on Back----------- ***If percolation test is to be conducted within 100' of wetland,Von must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q;SEPTIG,PERCFOR,\4.DOC DEEP OBSERViiTIO'HOLE LOG Hole# " Depth from Soil Horizon Soil Texture Sail Color Soil Other Surface(in-) (USDA) (Munsel() Mottling (Structure;Stones,Boulders_ Consistency %Gravel) cv -�d gw -1,5z, C, t�1��%vy �d b�k.��14 Lvos� DEEP OBSERVATION HOLE LOG Hole# 2.- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Viunsell) Mottling (Structure,Stones,Boulders- ........ .........................._......................._._....................................._........._.._._.........__.._._..........................................._........_. Cons tencv..°'e_Grat:e..l) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in) (USDA) (lt4unsell) Iottling (Structure,Stones,Boulders. Consistency.°'o Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil_ Other Surface(iri) (USDA) (Munsell) Mottling (Structure,Stones;Boulders_ _ Consistencv.%Gravel Flood Insurance.Rate Map: Above 500 year flood boundary No_ Yes Within 500 tear boundary No Yes Within 100 year flood boundary, No Yes Depth of llatui•ally Occurring Petvious Material Does at least four feet of naturally occurring pervicus material exist in all areas observed throughout the area proposed for the soil absorption system? L O5 If not,what is the depth of naturally occurring per,ti-ious material? certification p I certify that on�fl�' � 6 ("date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience describedin 310 CMR 15.017. Signature , (' r j Date Dec U, 2016 ' OF Mass c 9 Boa DAVIC yGs o D. U � COUGHANOWR Q ASEPTIC:PERCFORM.DOC `rp /cE N Sti10 Q- O EVAL'�PC 73 zl LO C•A,Tl0N S E AGE PERMIT NO. VILLAGE INSTA LLER'S NA IRE & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED. 7, ��,. �1 DATE COMPLIANCE ISSUED ^�o _g� t1�t I C G C r C / s r THE COMMONY.EEAL:rK OF MASSACHUSETTS YEB_lp.................. BOARD OF HEALTH AU...................OF.......... .0.1-C............................... Appliratiou for R-spoiial 10orko ToMitriartion runtit Application is hereby made for a Permit to Construct (),� or Repair an Individual Sewage Disposal System at: ................................................................................................. .................................................................................................. Location-Addr s or L&t No. ...... ..... .......Z...................................................................7 ..... r Address .................................. .............?qV ..................................................... Installer Address Type of Building Size Lot-lPt-11-a.......Sq. feet U Dwelling—No. of Bedrooms...................3_......._....._______.Expansion Attic Garbage Grinder (v4D) Other—Type of Building ............................ No. of persons---- ----------_---------- Showers Cafeteria Otherfixtures --------------------------------------------------------------------------------------------------------------------------------------------------- Design Flow................... ..............gallons per person per day. Total da��flow......... ...................gallons. Liquid capacity_/T4..'.9..0....gallons Length.......q..... Width-_____ Diameter................ Depth......4 9 Septic Tank ------- Disposal Trench—No..................... Width.................... Total Length____........._..____ Total leaching area--------------------sq. ft. Seepage Pit No----------/........ Diameter-___--- ------- Depth below inlet.._......._`..._. Total leaching area..Z-0.0....sq. ft. Z Other Distribution box (Y-) Dosing tank ( ) 4--oe-60— L04 Percolation Test Results Performed by....... . .............................. e6 ..........4... Date....4. ..... .. ................... Test Pit No. L<Z:......minutes per inch Depth of Test Pit.... Depth to ground water---A.AC.T.7.. Test Pit No. 2..-<.7------minutes per inch Depth of Test Pit.... Depth to ground water._Cww Eh i7,F 7 Z.. .........0 Description of ..................................................................... V .. ..... ..... U ............. ...... ...... ........... ... 7,1 4 �S/, 647_7.1 Z -0 .S Sel --------- . .... ... ..4---/......C.....6ze ---jK., AJ U Nature of Repairs or Al erations—Answer when applicable---------------------------------- ------------------------------------------------------------- ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T= 5 of the State Sanitary Code— The undersigned further agre noVo place the system in operation until a Certificate of Compliance has been issued b the bo A of health. JV2,-- ,s Signed.. ............... .................................................. ................................ Date Application Approved By............ ------------------------. .2. -1.5.-eb .............. Date Application Disapproved for the following reasons:................................................................................................................. ......................................................................................................................................................................................................... Date PermitNo........................................V................ Issued....................................................... Date N(ILI .. Fim$...�]. ...�....... THE COMMONWEAL�T_4i OF MASSACHUSETTS BOARD OF HEALTH awJ---------- --------OF......... .. Appliratiou for Elispusal Worko Tomitrur#ion Fautit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: _ Goy-........ Location-Addr s ................................ .•--......---------•----..........----...-or t No... .7r C,e 2T �s5 � lfo ' ec:D, lv,_......C_.v,v� �E ��- �f a......f .............•. -�--- --'•--. ............... ..... ..................... ---------------.-. .. ......- 40; r - Address 'Jkz .---•-- - Installer Address UType of Building 3 Size Lot_/Uj...11..a...__..Sq. feet I-, Dwelling—No. of Bedrooms............................................ Attic ( ) Garbage Grinder (AO) aOther—Type of Building ________-_-_••-------------- No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ..__.......-•-•-----------------------•--•-•---•-•---....-•-•-------'--•-----•-------•-------...-•------•---•---------•------•-••••---•••••••-•....... W Design Flow.....................�-..�<................gallons per person per day._ Total dail flow.........t3 3-_0........_...........gallons. WSeptic Tank—Liquid capacity&4J...gallons Length.......qL_..... Width................ Diameter................ Depth......4...... x Disposal Trench—No..................... Width.._....._._____... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../--------- Diameter........-.�-�..._..... Depth below inlet........6!..1.... Total leaching area.. _b U....sq. ft. Z Other Distribution box (x) Dosing tank ( ) 1-4 Percolation Test Results Performed by......6.�G.eG..... Ur,J c _GG Date___l _ Test Pit No. 1_ y......minutes per inch Depth of Test:.,Pit----ll✓' .:_.. Depth to ground water.._At� _7--------- f� Test Pit No. 2._�''__.—....minutes per inch Depth of Test Pit.--- .`�t.��. Depth to ground water......COO wiZZXarc� Q+' ------------------------------•-----...._.... ------------------ --------------- O Description of Soil-- /.._.._0.��----�•- ' �---L -� / 6 "— 7 Z _ �F3r �S/7�D ...5.4....... 4 p RJ.E .5 N ---------4� u iG U IZ.S �cJ i V Nature of Repairs or Alterations—Answer when applicable._-____......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with TT�-1'^ the provisions of ': t of the State Sanitary Code—The undersigned further agre noxt}plttce the system in operation until a Certificate of Compliance has been issued by the boayf of health. : �+ ✓ Signed_- .................................................. ................................ ,ram Date Application Approved By•-•••••--- .../�S` .'0--------•----- Application Disapproved for the following reasons----------------------------------------------------------------=--.;.........._.._--_.-__-__Date---• -------- -------------------------------------------- ---------------'---•----•-•---------.......-------•----------------'------------------------------------•------------------------------------...--•--- Date PermitNo......................................................... Issued................. -ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF......'04. '" *M-....................._.............. %Trrtifiratr of T:ompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (L-�/Or Repaired ( ) by............... .......... ,..• Installer has been installed in accordance with the provisions of T " `r `of TheSSanitary Code as described in the application for Disposal Works Construction Permit N __ .,��-�--........ da.ted----------------_-____`�_.__--_____-_-____-_- THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................ 1... 0/.. Inspector ..............' ................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....,,�GSI:?+te�ol. ................OF....: �k� .................................... �.�✓ No r' FEE.. e.......... Permission is reby granted........... - - • --_---------------------------------............................................... to Construct ( or Repair ( an Individual Sewage Disposal System at No........... •......2 d r 5 •. ---_ as shown on the application for Disposal Works Construction rt No___________________ Dated.. � ' PP P V------------------- _y DATE...................... -------��_......--------...._... Board of !pO fh- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in tow i' must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St, Hyannis. Take the completed form to the Town Clerk's Office,.1st FI., 367 Main St.; Hyannis,.MA 02601 (Town Hall) and get the Business Certificate yannis. required by law. e that is DATE: `�V..� APPLICANT'S Fill'n please: S YOUR NAME/S: I SU.n S �.. RW . � ;.� BU INESS YOUR HOME ADDRESS: I r,1 4 Tlit ELEPHONE # Home Telephone Number NAME OF CORPORATION �,L jZt NAME OF NEW BUSINES IS'THIS A HOME`OCCIIPATION7 XES NO` Tr PE OF BUSI&S—se= 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 the rules and regulations of the T Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST.GO TO 200 Main St. - corner Town of Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business n this toof w Yarmouth 4. BUILDING CO ISSION R'S OFF E This individ I ha infor .e o an 'er it r q irements that pertain to.this MUST COMPLY WITH HOME OCCUPATION type of businessRULES AND REGULATIONS, FAILURE TO Aut oriz i a u * COMPLY MAY RESULT IN FINES, COMMENT � ( _ i r - 2.. BOARD OF HEALTH l 1 This individual has peen��.i formof the permit requirements that pertain to this type of business. I _ f Y� U 18A, PL`�WITH ALL Authorized Signature** MUST ,OM COMMENTS: Zk AF?C , n'°TE.RIAI S REGI!!.. .3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business: Authorized Signature COMMENTS: r TOWN OF BARNSTABLE Date:P/ In l TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: iafMt I�� BUSINESS LOCATION: ( wln(s ' - INVENTORY MAILING ADDRESS: t- - 'Y� Q TOTAL AMOUNT: TELEPHONE NUMBER: C-1_4' CONTACT PERSON: J Y 0 r'1 EMERGENCY CONTACT TELEPHONE NUMBER: CQ �� to\MSDS ON SITE? TYPE OF BUSINESS: �! �'(k-C � YJ INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: 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 material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Divisibf -' 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) Miscellaneous 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 Miscellaneous petroleum products: grease, Photochemicals(Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) aulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW, ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initial COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i DEPARTmENT OF ENVIRONMENTAL PROTECTION i- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR] RECEIVE® PART A CERTIFICATION NOV 1 3,2002. Property Address: 14 Uncle Joe's Way AB LE Hyannis MA 02601 TOWN OF BAR C�EPEPN I TT. Owner's Name: Mark Goode HEALTH Owner's Address: Same Date of Inspection: October 23,2002 Name of Inspector: PATRICK NL O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. �® Mailing Address: 189 CAMMET17 ROAD MARSTONS MILLS MA 02648 PARCEL Telephone Number: (508)4284779 LOT _ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approval system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: // 6 Z_ The system inspector shall submit acopy 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. RNotes and Comments , ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use, Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Uncle doe's Way,Hyannis Owner. Mark Goode Date of Inspection: October 28,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.343 or in 310 CMR 15.304 exist_Any failure criteria not evaluated are indicated below. Comments: & System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution lox. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Uncle doe's Way,Hyannis Owner: Mark Goode Date of Inspection: October 23,2002 G 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 prow public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within I00 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Uncle Joe's Way,Hyannis Owner. Mark Goode Date of Inspection: October 28,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool T ` X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 67.below invert or available volume is less than'I2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface' water supply. X_ Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each ofthe following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Uncle Joes Way,Hyannis Owner. Mark Goode Date of Inspection: October 28,2002 Check if the following have been done.You must indicate"yes"or"no"as to each of the following. Yes No X — Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes ofwater been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? X Were all system components,excluding the SAS, located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X_ _ Existing information.For example,a plan at the Board ofHealth. X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Uncle Joe's Way,Hyannis Owner: Mark Goode Date of Inspection: October 28,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [ifyes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):No Water meter readings,if available Out 2 years usage(gpd)): 62 Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons1sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the'Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records None prior to inspection.Tank was pumped day after inspection. Source of information: Was system pumped as part of the inspection(yes or no):No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Maintenance TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any)No _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance Date 7/30/81 per As-Built card. Were sewage odors detected when arriving at the site(yes or no): No I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Uncle doe's Way,Hyannis Owner: Mark Goode Date of Inspection: October 28,2002 BUILDING SEWER X (locate on site plan) Depth below grade: 30" Materials of construction: cast iron -X_40 PVC other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints,venting,evidence of leakage,etc.): Pipe in good condition.No evidence of leaks'or backup. SEPTIC TANK: X (locate on site plan) Depth below grade: 3' Material of construction: X—concrete—metal fiberglass__polyethylene other explain) — — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 GaL 4.5'X 8' Sludge depth: 3 h" Distance from top of sludge to bottom of outlet tee or baffle:20" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle:' 8" Distance from bottom of scum to bottom of outlett tee or baffle: 7" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Recommended pumping tank.Structurally sound. Baffles are intact GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete metal fiberglass_polyethylene—other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:' Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlett invert,evidence of leakage,etc.): Page S of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Uncle doe's Way,Hyannis Owner: Mark Goode Date of Inspection: October A 2002 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explaia): Dimensions: Capacity: Lallons Design Flow: �allonsJday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present mustt be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box set level.Effluent level even with outlet pipe. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEINq S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Uncle Joe's Way,Hyannis Owner. Mark Goode Date of Inspection: October A 2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativelahernative system Typetname oftechnology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Normal vegetation and dry soil over leaching pit. CESSPOOLS:No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic Failure,level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page l0 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Uncle Joe's Way,Hyannis. Owner, Marls Goode Date of Inspection: October 23,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a.sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 3q 4� Z9 ZZ 3 �l.ng wls vN de- W a Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Uncle doe's Way,Hyannis Owner: Mary Goode Date of Inspection: October 28,2002 SITE EXAM Slope hone Surface water None Check cellar Dry Shallow wells done Estimated depth to ground water: More than 20 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet.of SAS) Checked with local Board ofHealth-explain Checked with local excavators,installers-(attach documentation) X_Accessed USGS database-explain: T.O.B.Website and USGS maps. You must describe how you established the high ground water elevation: Checked town groundwater contour map showing groundwater at or below elevation 30.Also checked USGS topo maps showing the property elevation at 50.Also showing Duck Pond located across Rt.28 at elevation 29. Bottom of leaching pit 9 feet below grade leaving 11 feet of separation. Commonwtrealth of Massachusetts � ,.. Title Official Inspecti n dorm ,. Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments Prop- y dd. ss — Owner :Wn r N me �— information is required d for ��0 every page. City own ` State Zip Code -- Date o I sped'on Inspection results must be submitted on this form. Inspection forms may not be altered in any wary. Please see completeness checklist at the end of the form. important: A. General Information -When filling out forms on the coin th 1 er,use only the . Insper�or: only e tab key to move your e cursor- et not Name o n. Qct '[�— _�(� use the return P- key. Comp ny Name _ Comp Fly A fess — z �d " City/To1vn State Zip Code Telephone Number License Number B. Certificat:iorl 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(AEI'approved system inspector pursuant to Section 15.340 of Title 5 (310 CIVIR 15.000).Tire system: Passes ❑ Conditionally Passes ❑ Fails [] Needs Further Evaluation by the Local Approving Authority Insp ctor's$rgna Lire Date r The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of hlealth or DEP)within 30 days of completing this inspection. If the system is a shared system--or has a design itc+uvl of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER.The original should be sent to the system owner car and copies serit to the buyer, Wapplicable, 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. . 15ins•09106 Me 5 Orridel Inspection Forth:Subsurface 5ewnge Disposal System•Page 1 or 17 .7- �/ A Commonwealth of Massachusetts `title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - Pro dress Owner Owner'S Name Information is required for _ 19 every page. City own State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E7 always complete all of Section D A) System Passes:- l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CIVIR 15.304 exist_Any failure criteria not evaluated are indicated below. Comments: � 5 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•09/08 - liUe 5 Orricial Inspection Fonn:Subsu,face Sewage Disposal System•Page 2 or 17 .I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Propqy7y dre , i � Owner Own Name information is I'll All required for 1 every page. City ow State Zip Code Date of Inspection B. C IrtifiCation (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): 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 16.303(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&a salt marsh t5fns•09/08 - Title 5 Mist Inspection ronre Subsurface Sewage Disposal System•Page 3 of 17 Conimonwealth of Massachusetts `title 5 Official Ins spoon Form Subsurface Sewage Disposal System Form-,tVot for Voluntary Assessments r ' .1 J P.S. ./j"V - Prope A dress Owner Own ame information is tin1, required for - U every page. City/Town State Zip Code Date of Inspection B. Ce ificaation (cant.) 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 systern 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 systern has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The systern has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0-l", 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 ❑ jZX Liquid depth in cesspool is less than 6" below invert or available volume is It*§s than'/z day flow tSlns•00108 Title 5 Official Inspection Form:Sgbsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h&/ Property dre s Owner 101wnerl e information Is 11 required.for every page. CityfTow tat! Zip Code Date of Inspection B. Ce fication (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: El L�r Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ LA' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ICI Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2/ 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 forma ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area.—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed tinder 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. 15ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of MassachusetU title 5 Official Inspection For > Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jr` 9 1 j "M Property A 19 Owner Owner's e information Is � Z) required for J � --- every page. City/Tow Staie 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? ❑ [, K 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 /0101 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, dirnenisions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with El 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): �' Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — .> 15ins•09108 Tille 5 Official Inspediun Fonn: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 rr Propel. Ad ress 161. �;,.' ; , 1", /_k Owner Owner e information is required for (p every page. City/T wn State Zip Code Date of Inspection' D. System Information Description: r s.. Number of current residents:. Does residence have a garbage grinder? ❑ Yes _® 'Flo Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes EJ No Laundry system inspected? ❑ YetNo Seasonal use? ❑ Yes 9 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No .Last date of occupancy: Ea �� 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massalchusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Porn-Not for Voluntary Assessments N 0A dl JAMV , Prope A dress ry Owner Ow r /W' I 'q ame / information Isudn tu ' L� / 0 required for s /// every page. City/T wn State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system r°❑ 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): l5ins•08/08 Me 5 Official Inspec8on Fomc Subsurface Sewage Disposal System Page 8 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property d ss Owner Owners rjarpe information is �• (►1 /a.- /)! /7�/ ✓7 required for HIM 0 J l I/�1 (�o� Ir every page. cityrrowA State Zip Code Date of Inspection D. Syst6m 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 P--'No Building Sewer(locate on site plan): Depth below grade: feet Material of construction:Y40 ❑ cast iron PVC ❑other(explain): 2 i Distance from private water supply well or suction line: teat Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth.below grade: feet Material of construction: 04 concrete ❑ metal ❑fiberglass ❑polyethylene 1 ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ce�ertificatee)ei ❑ Yes ❑ No . Dimensions: <�� Sludge depth: z r/ t5ins-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 i i I ' Commonwealth of Massachusetts Title 5 Official Inspectiop Form Subsurface Sewage Disposal System For -Not for Voluntary Assessments e_ - Prope �dd7�P ss Owner Owner ame information is /s {�) �o( � z) required for 11 1 I every page. cityiro n 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 �� Distance from top of scum to top of outlet tee or bafflel``�— 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.): �/ ma's t✓ %�G" !� ��'�i.�/y ✓A9 -1zle i'��00�� 0.f T 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 15ins•09= Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F, rm-Not for Voluntary Assessments Prope dd ss .:C Owner information is _ Gl J ()p C� f A / regUifed for 6 `'.�/ ! every page. Cityfr wn State Zip Code Date of Inspection il. System Information (cunt.) 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 Molding 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 plow: 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 t51ns-09/08 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-page 11 of 17 a ' Commonwealth of Massachusetts Fill Official Inspection Form Subsurface Sewage Disposal Syste . Form-Not for Voluntary Assessments Prope►ry Add' ss Owner Ownerame information is required for - ,V"�W(5 every page. CityfTo n 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 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.): 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: l5ins•08/0a Title 5 Official Inspection Foan:Subsurface Sewage Disposal Systern.Page 12 of 17 • 4 _ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrii-Not for Voluntary Assessments -P—roperiy Mless V Owner owner's me information IsHIM required for every page. Cityffo n State Zip Code Date of Inspection D. System Information (cont.) Type: i, leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A �p ev �✓t�l'�� .�/��'.�s' �,�� _,��' �� /.�L'��G sit�� -- 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments Prope dress Owner OwneName information is 1 �f JZ1 required for � `� tv / every page. Cityrro n State Zip Code Date of Inspection D. Systems Information (cons.) 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.): 15ins-09108 Title 5 Official Inspedion Form:Subsurface Sewage Disposal Syslem-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form-Not for Voluntary Assessments Prope diress rX -W !I _66 Owner. Owners me information is t required for [hi every 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 0 Q z' %d e� 90 (21 � o �r } t5ins•09108 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System form-Not for Voluntary Assessments Prop A dress AR- Owner Own e information is required for 11 every page. Cityrro n State Zip Code Date of Inspection D. Sys sm Information (cent.) Site Exam: FeKCheck Slope r Surface water heck cellar /-2r [)--Shallow wells Estimated depth to high ground water: et 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 IJSGS 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. t5ins•09f08 Tilla 5 Official Inspection Form:Suhsuiface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title Official Inspection For Subsurface Sewage Disposa�SysttemF- rm-Not for Voluntary Assessments / Prope dress Owner OwneY ame Information is 5 required for �II�UL every page_ City/T wn State Zip Code Date of nspe6 ion E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed I�✓1 Sy tem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 PREFERRED HOME INSPECTION SERVICES, INC. P.O. Box 196 • Halifax,Massachusetts 02338 ®� o (617) 294-0272 800-268-4998 July 2, 1996 � 1` k �,A �7 A�r Barnstable Board of Health l VI 6 i . P.O. Box 534 a�Q , Hyannis, Massachusetts 02601 RE:Title 5 Inspection Dear Health Agent; In conformance with the rules and regulations and standards promulgated by the Department of Environmental Protection a Title 5 inspection was conducted at the following location in your jurisdiction. _-- Maureen R. Goode A)Uncle Joe's Way Hyannis, MA 02601 Enclosed as required by statute, is a completed cony of the inspection report. If we may be of any additional assistance please do not hesitate to contact us. f Respectfully; it anzes . Schilling State Certified Title 5 Inspector "Your Complete Home Inspection Company" r PREFERRED HOME INSPECTION SERVICES,INC. Commonwealth of Massachusetts Po.sox tss - Halifax,Massachusetts 02338 Executive Office of Environmental Affairs Department of Environmental Protection...., WU m F.Weld Trudy Coxe Argeo Paul Cellucd u ootwenor 1 f b u•} t ��,i�`4, a. Sp�l:fi,V �J .r., +, 3 , �; <ny�, SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION,FORM J r. �• ` PART A-,' ; r CERTIFIGTION, } � , props Add{' , 1` Uncles,Joe'sx Way: Hyann, ress<of Owner Same Date of I�ectioe 'July,' 2, } 19k96 � " ; pf different) Name of Inspector. 'James, J Schilbeling'" Company Name,Address and Teleplvone.Num Preferred"%Home, . Inspection Ser`vices Inc P O Box 196 Halifax,`r' NIA 02338 CERTIFICATION STATEMENT- t certify that 1 Have personally inspected the sewage disposal',system at this address and that the information reported below is true;.`accurate and complete as.:of the time ofk ins pectlon,The Inspecx+on`was performed based on my training and experience in the proper function and R{aIr112n0e of on-stte sewage disposal systems ':The system t m t K s X �Passes'�..��.r� .S;�w'�• � �`4Y Vzd � a�,e,.T F�� ; y4�.�' 'x',kC 5 ' ,k �,n: i�� k: � it.. COndttonay lll Passes c I' t N4F AS�y'6C { l =t�sY`"'k2. '4C ✓ 1'13 �` Nceds Further Evaluation By the local Approving Authoryl 6 a Y°C r Fail$ - a .• �. ;. _,k a ea �'�` � V�:CS rG v? .� M..t �. r y > i 4r e rf a - r L�r h Inspector's Signature: "� ; �4 Date�31, uly l, 19 l+ 4 ,�. •k f ai4 -0b.; .d,kt2'.r �'✓ 41?Y `, The System Inspector shall submit a Dopy„of th+s inspection report'to the'Approving Authority within thirty(30)days of completmg_th+s inspection.-, If the`sy stem,is a shaied,'system of has a design flow"of 10,000 gpd or greater;the mspecxor and the system owner shalt submit ' the report to the appropriate regiona6office of the Departmenf .6f Environmental Protection The original should be-sent to the system,owner and copies sent to the buyer,'if applicable and the approving authority P .Nt ,.,;ti 4 J ,yam_ •f. .. INSPECTION SUMMARY: Check A, B,C,or D: Aj SYSTEM PASSES: ' XK_ 1 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 replanement or rerair, 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 ' One VAntsr Street • Boston,Massachusetts 02108 • FAX(617)W6-1049 • Telephone(617)2924MW A 40 Printed on Recycled Paper • i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. 1 Uncle Joe ` s Way Hyannis NIA Owner: Maureen X. Goode Date of Inspection: July 2 , 1996 61 SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to'broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed t distribution box is levelled or replaced The system required pumping,more than four times,a-year,Aue to broken.or obstructed pipets).-jhe.system will pass p inspection if(with approval of,the Board of Health): broken pipe(s)are replaced obstruction is removed u ...t C).FURTHER EVALUATION IS REQUIRED.BY THE BOARD OF HEALTH: r Conditions exist which require further evaluation by the Board.of Health in order to determine if the system is failing to protect the r -•., 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: w 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." . rr Z):. -,SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND.PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT f 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 eoliform bacteria and volatile organic compounds indicates that the Well is fare from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. I 3) OTHER I •. I (revised 11/03/95) 2 PREFERRED HOME INSPECTION SERVICES,INC. PO.BOX 196 Halffax,Massachusetts 02333 SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Uncle Joe Is Way, Hyannis MA 02601 Owner Maureen R. Goode Date of In spection: J u l y 2, 1996 131.SYSTEM FAILS: N/p a have determined that the system violates one or more of:the following failure criteria as defined in 310 CMR 15.303. The basis , r : , ry for this determm natlo is identified below The Board of Health should be contacted to determine what will be necessary to correct r= the failure rfM '4 Ala �' ti" .-• *-.• ;fit.y,.�+�� 1 � .,. <x t� ;�,: Backup of sewage into.facdrty or system component due to an overloaded or dogged,SAS or Cesspool. } F Y 5� . ,}° Sax•J' �.,g��Y1" ��l'rtoE ex=ry �' .:_( E '_":� - '.r v „-. '� .: �.'..; UW 4,�f ge Dischar 'or pondin of f sS effluent to the surfaee`of the ground or surface waters due to an overloaded or.dogged SAS or ''4: ! Y �i5-,.cesspool 1 Y •<.TJ.t to �� _ ` . Static liquid level in the.,distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. _ ,Liquid depth in cesspool is less than 6"below invert of available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year'NOT due to dogged or obstructed pipe(s). x x Number of times pumped " � ;: t � . ! 5 _4 i '..S -- r it 1 ti :t 7 •�� . � . .. - r Any portion of the Soil=Ab50rpt�on System,cesspool or privy�s beIOW the high'groundwater elevation^ I _; ri 'ew, r�'`' �r f,-tt y,l t.�yi€ I� ' xS5 >�f` des. 7�5'.k � .,' ,.:.r° 1 ;:.>:'7 ';,� �. �':.. Po ',.a rn•' jj. Any portion ofa cesspool or privy rs within 100 feet of a surface water supply or tributary to a surface water supply. SoC' 4 `s_ 5 . Any port�on'of a cesspool or privy is withm a Zone I of a public well 4 LxXt} � 3 Any portion ofa cesspool}orpnvyyrs within 50 feet of'a private water supply well a ,R�sx h a , Any portion'of_a cess 'o�I or n is;less than�100 feet but reater than 50 feet from a private water supply well with no, P� P �'Y 8 P PP Y $ x: acceptable water,quality analysis .'If,the well has-been analyzed..to be acceptable,`attach copy-of welF water analysis for r '* } 4 ._` '� ,� = coliform bacteria,volatile organic compounds' ammonia nitrogen and,nitrate.nitrogen . y E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: _IL/A The system serves a facility with a design flow of 10,000 gpd or greater(large System)and the system is a significant threatto public health 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 Onterm Wellhead,Protection Area(hNPA) or a mapped 7_nne 11 of a public water surpli well) The owner,o'r operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 Uncle Joe 's Way Hyannis MA U2601 Owner. Maureen x. Goode Date 0f fe`Pft1kM' July 2, 1956 Check if the following have been done: -.!,Pumping information was requester}of the owner, occupant, and Board of Health. s X None of the system components have been pumped for at least two weeks and the during drat period, large volumes of water have not been introduced into the system has been receiving normal flow rates.. system recently or as part of this inspection. X As burp plans have been obtained and examined. Note if they are not available with WA. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flaw X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System,.have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. r -�The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from Surface Di owner) were provided with information on the proper maintenance of Sub- (revised System. , I . I (revised 11/03/95) 4 PREFERRED HOME INSPECTION SERVICEC,INC. P.O.Box 196 HaWax,Massachusetts 02333 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: : 1 Uncle Joe' s Way Hyannis MA Owner: !Maureen R. Goode Date of Inspection: July 2, 1996 FLOW CONDITIONS RESIDENTIAL- Design flow-._LL 5 U.Jallons Number of bedrooms:_ Number of current residents: i Garbage grinder(yes or no):•_jo • Laundry connected to system(yes or no):, Seasonal use(yes or no): 1�1c� Water meter readings, if available: T7n1cnnwn Last date of occupancy: ('urrent COMMERCI ALA N D USTR I AL: Type of establishment: N/A Design.flow aallons/day - t Grease trap present (yes.or no) Industrial M!aste Holding Tank`present'(yes or no)_ r € Non-sanitary.waste.discharged to the Title 5 system: (yes or no) Water,meter readings:..,if available: .ast date of occupancy x . OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION rIt PUMPING RECORDS and source of information:' Owner GtarPd that i t t,ari hcnn n�sor � 3=eel=eaEs Sias a to pump System pumped as part of inspection: (yes or no) No .If yes,volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM xy Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy _gyp_Shared system (yes or no) (if yes,attach previous inspection records, if any) Odw(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: Instal l Pc ot1_Z/2 6/R Ra n-s Gable BUH records Sewage odors.detected when arriving a the site: (yes or no) N O trevised 11/03/95) 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Untie Joe' s Way Hyannis M4 Owner. Maureen R. Goode Date of Inspection: July 2 , 19 9 6 SEPTIC TANK:_X (locate on site plan) Depth below grade: 33 Material of construction: "concrete_metal FRP other(explain) ;60 br.;D cover 9"- from surface Dimensions. 10 x 5 ti" x b 8" Sludge depth: ,1 Distance from top of sludge to bottom of outlet tee or baffle:" Scum thickness. 3=i Distance from top of scum to top of outlet tee or baffle: 10.: Distance from bottom of scum to bottom of outlet tee or baffle:_ 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.) troth inlet and outlet tees are intact anti are working properl v. Owner advi sf-rl that -;ys'�Pm shoUld--be pumped at least once every three Year!4 GREASE TRAP: N/A 1 (locate on site [Tan) / Depth below grade: Material of construction: _concrete_metal_FRP—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: 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.) (revised 11/03/95) 6 PREFERRED HOME INSPECTION SERVICES,INC. P.O.Box 196 . Halifax,Massachusetts 02333. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Uncle Joe ' s Way Hydnnis MA Owner: Maureen R. Goode Date of Inspection: July 2 , J-9 9 b TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: - Material of construction:_concrete_metal_FRP._other(explain) l f . Dimensions . Capacity:i plions.- Desi n(low: 8 Ilons/da as y /Harm level: Comments: 1 (condition of inlet tee,condition of.alarm and float.switches, etc) s. ,r' A. `T - • _ DISTRIBUTION BOX. X' n x (locate on site plan) Depth'of liquid level above outlet invert: Comments (note if level and distribution is equal,evidence of solids carryover, evidence of.leakage into or out of box,etc.) hnx:H, G " l"ava" " anri rl Aa, „ Sri.=-Sol ias No leakage was detected PUMP CHAMBER: N/A (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/9s) 7 . f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 uncie Joe ' s Way Hyannis MA. Owner. Maureen R. Goode_. Date of Inspection: July 2 , 19 y 6' SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible; excavation not required, but may be apprcximated by non-intrusive methods) If not determined to be present,explain: Type. leaching pits, number: X leaching chambers, number:_ leaching 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 vegetation,etc.) No Sig of ponding or hydraulic failure, No sign of water leakage in to the pic,. Tiie soil s owei no signs of high water, CESSPOOLS: N/a (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(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: N/A (locate on site plan) i Materials of construction: Dimensions: Depth of solids: Comments- !note can&tion of su:l, s;g.-s of hyd odic 41u(e, lavil of-)end;%, ,n,iaion of v:.geta_ioi., .etc.) I (revised 11/03/95) 8 PREFERRED HOME INSPECTION SERVICES,INC. . P.O.Box 196 Hal lax,Massachusetts 02333 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART C SYSTEM INFORMATION (continued) property Address: 1 Uncle Joe' s Way, Hyannis MA ! Owner. R. Goode $ , Date of Inspection: July '2 , L996 ` ' ha" tt ,1 f, �e 3' } G R _SKETCH OF.SEWAGE DISPOSAL SYSTEM. �r{ !:'.y �' w tier t". 7 �n. '� '' t w 3 x ; ws'§:' F`ju ,Include ties'to at least two t references Iarldrnaft or bends n iks'14``} ,'° y+ :, Yt"•.:.i p y.. 2f}y` ,r+{..�nen_.w'r 'i krn •z�f s � at<zf �f rYSk� t{4`r�tb t5' 2"dRs {rSfk'q.:}era-. "'.°t:.� yw crr � u �' � J : sC �±ax � bate all Wells Wlihln>.�� Na ,.: 7 }c s 3r is as r" s°-s. ",k'°K4t�sa -n .';:'� '4 af .,. tN� „ �, TH1'S• Di2AWiNG :1S :NUTT.(7..<SCALE'f r it �$.. 'wk� •>, x•A' r. a:':} 4 ,' sg ,�k > * ..w, ;`! „5 rda xv .;.;i' { c.•Y;<e'.. ?. -'h �$' ^.,v `t '{ P Y. F '±fa fi s Nf�:_, '"Y4:'"g, Ow", .. s"`,.,d.": "' `+i}'' 4,> `'kw¢k d... !-y. 'r.-•4`i ".}>aS.. a... v s +;•;. 4 •'; Kr s.. n.?n.s '` '"�"t, ., n. � r l- a u ± h x. :.v. �` , „4 $,�>,. r, {a., `,r:k,..kY .ih nt 8 +�*."•'.. 9a' C.:t d ..k 7„ tt„ }: , e , ,. ... '* .'*Z€ „S r :'ai•. ,^'t,+5.crt iy ut 4 v. ., ,��.F v;'.t•. ,1.K,: kw: t�. ,t: Y,,. 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O O r U" O { D � D m ZE HYANNIS, MA Q P WATER LINE - WATER GATE O GAS LINE --r�G OVERHEAD WIR OH _� UTILITY i! P POLE, fL GARB G 1 OT i P��O b OWED e � ► e ► e, �S Z l o G4'I 0 rt PROPOSED SOIL � a A8SORPTION SYSTEM " v -SEE DETAIL 53�.i m = ON BACK N OO 1 �Oq 6ifi. / 12 ft ll ❑U -c 52 1 V r'J .57 50 12 in ° OAK i3 1 U 2 off DRIVEWAY 21 ft OH I SHELL off 1 9 D T -- /p� /� /�\p v AREA - 70770 sf+ L�EGE D TO SL ROW � V��I � � M( SEPTIC COMPONENTS i- A LAND COURT PLAN 06,14-E k � n EXISTING 0 I ASSR MAP ,2 SHE 1060 GAL ® M 0 SEPTIC TANK ® 31U 11 d ' �+ ft OEXISTING _ t �7. o O `� 24 in LEACH PIT/ -i ROOM OAK i CESSPOOL DISTRIBUTION BOXY I I + TEST PIT •o I w x EXISTING LEACH PIT TO BE PUMPED AND (3 MINIMAL — \ FILLED OR: REMOVED GRADING -� 1 PROPOSED a O /. 1 G I SHELL DRIVEWAY PLAN 53 SCALE: I in = 20 ,ft \ 0 20 4 �c � IAn,� 0 1 / 0 )0 20 p p�H5tA8LE GIS pgTU�j 1 PRINT ON 11 X 17 in ELEVATION I _ �_ �� PAPER FOR PROPER SCALE 53:8.5 50 , TOp Of FOl1N0P�\�� 52 51 1 I a 1 �/ { , oFss tH old o�T` SEWAGE DISPOSAL o� DADVID 9ryG� DAVIDSS9�yG �y SYSTEM PLAN D. -TO SERVE EXISTING DWELLING o " COUrGHo. 10 OWR H COUGHANOWR LUANA AND 93 ImsN 461 DALLYSON SALVADOR Grp aGQG �F(`il _1PPRO 0 �� OWNER(S)'OF RECORD 14 UNCLE JOES WAY HYANNIS, MA (., 155 G90 Ryder Rd $ PROPERTY ADDRESS Chatham, MA 02633 Davidcou®Hotmail.com DATE DECEMBER 11, 2018 508 364-0894 =1-jDBv ETE-4350 ,�ecoe a am IL TEST [LL,OG CALCULATWHO SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE *461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS NO IF IN TEST PIT P RC AT 50 in - 2RMIN/NCCHnINECESOILS SOUNDUSEI NG STIR CTURAL CONDITION• IF NOT.KINSTALL ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER NEW 1500 GALLON SEPTIC TANK. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 53.50 0-10 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: 51.00 10-30 Bw LOAMY SAND 10 YR 4/6 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 30-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 42.50 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. NO GROUNDWATER ENCOUNTERED THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY TEST PI T IT 2 2 MIN/INCH IN c SOILS DEPICTED BELOW CAN LEACH: DEPTH SOIL SOIL OTHER ELEVATION IN S L USDA SOIL SOIL COLOR L INCHES HORIZON TEXTUREMOTTLES BOTTOM AREA = (24 x 12.5) = 300 s ft. (MUN SELL) G 53.60 0-10 Ap LOAMY SAND 10 YR 3l2 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 so. ft. TOTAL AREA = 446 s ft. 50.93 10-32 Bw LOAMY SAND 10 YR 5l6 NONE FRIABLE FLOW CAPACITY = 0.74 x 446 = 330.04 Cal dQ 32-138 C MEDIUM SAND 10 YR 514 NONE LOOSE 9 y 42.10 INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED BELOW" FLOW CAPACITY = 330.04 goI/dog WHICH EXCEEDS THE 330 gal/dog REQUIRED FOR A THREE BEDROOM DES4GN. 1000 GALLON SEPT§C TANK EXISTING UNIT — DIMENSIONS & DETAIL SO§IL ABSONRUP— VON TANK TO BE PUMPED DRY AT TIME OF INSTALLATION S YS'j]'EM CONSTRUCTION DETAIL AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. REPLACE WITH A NEW DRYWELL 24.0 ft I in 1500 GALLON TANK UNIT TAPER IF CRACKED, ROTTED M coz OR OTHERWISE - w COMPROMISED. 4 m In C C N ® (V co co O I o. � NOT c STONE- TO 3.5 ft 8.5 ft 8.5 ft 13.S ft LO SCALE 500 GALLON DRYWELL 8 ft—( in �� DIMENSIONS & DETAIL INSTALL ONE INSPECTION RISER TO WITHIN THREE INCHES OF FINAL GRADE INLET OUTLET H 50 & INDICATE LOCATION CO VER CO VER UNIT ON AS-BUILT ,��rti DROP 01 33 jf,3 /NFLOW LINEain FROM PBUILDI10 in = 14 TO f� p10 t^ D-BOX 48 in � LIQUID GAS 102 in LEVEL BAFFLE, CROSS SECTION VIEW INSTALL AN APPROVED GEOTEXTILE FABRIC OVER STONE 6 in STONE BASE IF NEW SEPARATION BETWEEN INLET & OUTLET TEES NO LESS THAN LIQUID DEPTH 3/4 m TO 24 in c 3/4 m TO , CROSS SECTION VIEW 28 1-1/2 !n GRAVED EFFECTIVEeI-1/2 in GRAVEL# in �, o DEPTH o;� 46 in 58 in 46 in WSTM�VT�OUv L0 DB 3 H20Y 150 in DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN -INSTALLER TO OBTAIN DISPOSAL WORKS �j11JJ��JJ PERMIT BEFORE STARTING WORK. -ALL COMPONENTS INSTALLED SHALL MEET �:� 12 in THE MINIMUM REQUIREMENTS OF MIN O MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). LO I c -INSTALLER TO VERIFY LOCATION'S OF ALL N FROM (n TO UNDERGROUND UTILITIES BEFORE O ^ SAS EXCAVATING FOR SYSTEM. Ai T -ECO-TECH ENVIRONMENTAL RECOMMENDS 6 in STONE BASE THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC 21 in 21 CROSS SECTION VIEW PUMPING OF THE SEPTIC TANK. ' -SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 40 PVC EL 53.85 +— b in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 53.50 D-Bo { 3' 1 USE H-20 M A X [�}n{�STpp��ppJG 51.0 �EXISTING1000 GALLONo°a°e0000° ° a. 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