HomeMy WebLinkAbout0053 UNCLE WILLIES WAY - Health 53 Uncle`Willies:Way
Hyannis
026
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYicatiou for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(. ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Locatio�Add���Nod Owner's Name, ddre�d T p X lj
Assessor's Map/Parcel
Installer's Name,Adiitess,an Tel.No. � � G Designer's arr
Address,and Tel.No.
t
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(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
Natur of Repairs or Alterations(Answer when applicable) ,yE' 7�l• 2i ��
J
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 he Environmental Code and'not to place the system in operation until a Certificate of
Compliance has been issued by this Bo d of
Sig Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construttion 3permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at
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 permit.
Date Approved by
No. Fee
THE COMMONWEALTH OF"MASSACHUSETTS Entered in computer:.,;'
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
f applica`tion for Misposal *pstem Construction permit -
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location or Lot No Owner's Name,Address, T 0.sy
�l �!�
Assessor's Map/Parcel
i
' Installer's Name,Address,an jel.N ALL Designer's Name.Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
i
i
Plan Date Number of sheets Revision Date
Title
J Size of Septic Tank Type of S.A.S. i
Description of Soil
{
3
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 arid`not to place the system in operation until a Certificate of
Compliance has been issued by this Bo d of e th.
i
Sig d Date
Application Approved by Date _
Application Disapproved by Datep
for the following reasons
ii
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
i
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC.HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
Misposal &Pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(
System located at
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 permit.
Date Approved by
��Y
I
1 Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y p
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, IVJ„
use only the tab 1. Inspector:
key to move your
cursor-do not `
David D. Coughanowr, IRS
use the return
key. Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
September 15, 2013
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 OffiVCFSubsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every _ Y p
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 CNIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
Inspect and clean septic tank outlet filter as needed.
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,
r, 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. F"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the(Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every _Y p
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies Way
M
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15 2013
required for every y P ,
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 Ely p 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, 'or 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 iin cesspool is less than 6" below invert or available volume is less
than '/day flow
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy:lem•Page 4 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is P required for every y H annis MA 02601 September 15, 2013
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 th&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..l have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is.within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you' have answered."yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y P
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been do-ie. 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 p'ans 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 construct on,
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): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15 2013
required for every _ Y p ,
page. Cityrrown 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 last 2 ears usage 154 gpd
9 ( Y 9 (gpd)):
Detail:
2011-2012
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
r.
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the nspection? ❑ 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):
Aero-Stream Aerobic System Restoration unit
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is H annis MA 02601 September 15 2013
required for every Y P
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:
14+ ears. Certificate of Compliance for infiltrators stem issued 8/20/99 Permit#99-431
Y P Y ( )
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: '1.5
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: 8.5 x 5 x 6-1000 gallon
Sludge depth: 4 in
t5ins-3/13 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
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structura integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years. Tank
and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Aero-Stream unit was operating. Outlet tee filter was found to be clogged and was
removed, cleaned, and reinstalled. Inspect and clean filter as needed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
,M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y P
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):
c
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.):
*Atta
ch co o current pumping contract(required). Is co attached? Y N Yes o
copy p P 9 copy ❑ ❑ ,
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is p
required for every y H annis MA 02601 September 15, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be cpened) (locate on site plan):
Depth of liquid level above outlet inver. at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Some solids in sump.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is p required for every y H annis MA 02601 September 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type: .
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
1
❑ leaching trenches- number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no standing effluent was observed to a depth of 10 inches below the top of
the peastone layer.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2013
required for every y p
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
C
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
F 53 Uncle.Willies Way "
Property Address
Stephen and Deborah Daniell-
Owner Owners tame
information is required for every Hyannis 02601 September 15,2013
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 referenda landmarks or bmnchmarks. 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
. ,
WAY
t5ins 3113 7illa 5 Offidal Inspection Form:Subsurface sewage Disposal System•Page 55:gr 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 53 Uncle Willies Way
Property Address
Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15 2013
required for every y p
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
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Departmen=records indicate that the property is over 20 feet above
groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins-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
c,M 53 Uncle Willies Way
Property Address
n Stephen and Deborah Daniell
Owner Owner's Name
information is Hyannis MA 02601 September 15 2013
required for every y P
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
4
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
_ l
DavidI Burnie Manct9Inc.ement In
3 Perry's Way .
.Harwich, MA 02645
508-432-0223 1-866-980-1440
Fax 508-4304450
Barnstable Board of Health
200 School Street
Hyannis,MA 02601
December 21, 2010
Referencedl11nc1e Will emRoad-jXyann:�s,�
On December 17, 2010,David J. Burnie Management,Inc.responded to a septic
backup at the above referenced address.
I observed the following:
1. The septic tank was overfull.
2. During pumping we had an estimate of five hundred gallons runback from the
leaching area.
3. We performed a Title V inspection and found the system to be in a state of failure.
and submitted it to the health department.
I discussed this with Mr.Thomas Mc Kean and we did an emergency repair using the
Aero-StreamR remediation process. I look forward to your.January 11, 2011 meeting to
discuss this procedure with the Barnstable Board of Health and to hopefully receive
permission to continue toJoffer the Aero-StreamR process to other property owners.
Respectfully Submitted,
David J. Burnie
General Manager
Licensed Installer and Certified Title V Inspector.SI#386 _
DjB/rmb .
e'rxo s. rozlffll
6/7/10 _
Don Burcham
Sales and Technical Support.
Aero-Stream@ LLC
To Whom It May Concern:
The David J Burnie Mgmt, Inc. is an authorized installer of the Aero-Stream@
equipment. His company has the ability to install and maintain our units in all
residential and commercial applications. His company has been trained in the
use of the Solinst Levelogger and Barologger-equipment. His company has the
software to collect the needed quarterly information from the installed units.
Sincerely
Don Burcham
877=254-7093
5_y
W300 N7706 Christine Lane Hartland,Wl
262-538-4000
www.aero-stre.am.com info@aero-stream.com:
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENERGY& ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
DEVAL L.PATRICK IAN A.BOWLES.
Governor Secretary
TIMOTHY P.MURRAY LAURIE BURT
Lieutenant Governor
Commissioner
APPROVAL FOR REMEDIAL USE
Pursuant to Title, 310 CMR 15.000
Name and Address of Applicant:
Aero-Stream, LLC
W300 N7706 Christine Lane
Hartland, WI 53029
Trade name of technology: Ae'ro-Stream Aerobic Septic System Restoration Process Models QT
800HMA, 800HHMA, 800UHMA and 800EHMA(hereinafter called the "System"). Schematic
drawing of a typical System and Technology checklist are attached and are a part of this
Approval.
Transmittal Number: X22441
Date of Issuance: January.27, 2009
Expiration date: ' ' January 27, 2014
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310.CMR 15.000,the Department of
Environmental-Protection hereby issues this Approval for Remedial Use to: Aero-Stream, LLC
W300 N7706 Christine Lane, Hartland,WI 53029(hereinafter"the Company"),approving the
System described herein for Remedial Use in the Commonwealth of Massachusetts. Sale and use
of the System are conditioned on compliance by the Company and the System owner with the
terms and conditions set forth below.Any noncompliance with the terms or conditions of this
Approval constitutes a Violation of 310 CMR 15:000.
-- January 27, 2009
H lenn aas, Ac ing Assistant Commissioner Date
Bureau of Resource Protection
This information is available in alternate format.Call Donald N1.Comes,ADA Coordinator at 617-556-1057.TDD#1-866-539-7622 or 1-617-574-6868.
MassDEP on the World Wide Web: http:l/www.mass.gov/dep
Z� Printed on Recycled Paper
Approval of BRP WP61a—Certification for Remedial Use Page 2 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
I. Purpose
1. The purpose of this Approval is to allow use of the System in Massachusetts, on a
Remedial Use basis to repair systems failing to protect public health and safety and the
environment where failure has occurred as described in 310 CMR 15.303 (1) (a)(1)and
(2)due to clogging of the soil absorption system(SAS). .
2. With the necessary permits and approvals required by 310 CMR 15.000,this Approval
for Remedial Use authorizes the.use and installation of the System in Massachusetts.
3. The System may only be installed on facilities that meet the criteria of 310 CMR
4. This Approval for Remedial"Use authorizes the use of the System where the local
approving authority finds that the System isfor upgrade of a failed, failing or
nonconforming system and the.design flowfor the facility is less than 2,000 gallons per
day (GPD).
II. Design Standards
1. The System is designed to convert an anaerobic system into an aerobic system and reduce the
strength of the wastewater received by the existing soil absorption system(SAS).Prior to
System installation the septic tank must be pumped to remove settled solids. The System
consists of an Aero-Stream aeration unit, 120 volts operated on a continuous basis,with an
airline piped into an existing septic tank or a new septic tank designed in accordance with
310 CMR 15.223 through 15.228. The airline feeds a•Micro Bubble Diffuser with floats
within the septic tank. The adjustable floats are connected to the airline and keep the diffuser
suspended at the proper level in the tank,typically'18.inches from the bottom.
2. Aerobic treatment is established„iii the septic tank and maintained using the Aero-Stream
aeration unit. The aerator mixes the contents of the septic tank with the bacteria and aerates
the wastewater. The System's biomass reduces the strength of the wastewater in the septic
tank. The aerated effluent from the septic tank is designed to reduce the thickness of the
existing biomat in the SAS,thereby improving the soil absorption capacity.
3. Prior to installation of the System,.the site shall be evaluated in accordance with 310 CMR
15.100 through 15.107. The existing.on-site system including the septic tank,distribution
box.and SAS shall be inspected in accordance with 310 CMR 15.302.
4. The System shall not be proposed for installation where:
•
A. The high groundwater elevation determined in accordance with 310 CMR 15.103
would be less than two feet below the bottom of the SAS.
B. A facility for which the site investigation indicates that the existing onsite system was
designed and installed fora design flow smaller than required by 310 CMR 15.203.The
minimum area for the existing SAS shall not be less than 50 percent of the area required
in accordance with 310 CMR 15.242.
Approval of BRP WP61a—Certification for Remedial Use Page 3 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
C. The existing septic tank(s)has not been tested and shown to be watertight.
D. The proposed installation is for a failed or failing leaching pit or cesspool.
E. A site investigation indicates that the existing soil absorption system must be removed
and replaced prior to installation-of the System.
5. The System shall be.equipped with a monitoring device that provides data-collection to
include tracking the elevation of the effluent in the SAS,and temperature. The data can be
stored and reported to include high,low and average levels for each parameter each month
and daily values for the last thirty days.
6. For seasonal use,the System'operator shall witness reactivation of System at each start-up
and ensure System mori`toriiig is recording properly.`
III. Allowable-Soil Absorption System Design
1. The following reductions are allowable when evaluating the System:
A. The approving authority may allow up to a 50 percent reduction in the existing soil
absorption system required by.310 CMR 15.242; or
B. The approving authority'may allow a reduction in the required separation between
the bottom of the SAS and the high groundwater elevation of up to two feet. This
provides a minimum separation of two feet(in soils with a recorded percolation rate
of more than two minutes per inch)or three feet(in soils with a recorded percolation
rate of two minutes orless per inch);or
C. The approving authority may allow a reduction in the required four feet of naturally
occurring pervious material in an area with no,less than two feet of naturally
occurring pervious material,provided that it has been demonstrated that the four
foot requirement cannot be met anywhere on the site.
EXCEPTION: If a remedial Systeni needs more than one of the allowable reductions
listed above,then the reductions must first be approved by the local approving authority
and then approved by the Department pursualifto`310 CMR 15.284 through filing a
BRPWP 64c permit application.
2. Additional.reductions allowable when evaluating the System:
A. When using IA, 113,or 1 C above_for the System where full compliance with 310 CMR
15.000 is not feasible, the local approving authority may consider granting local
upgrade approvals in accordance with the provisions of 310 CMR 15.401 — 15.405.
For example:
i. When an applicant chooses up to'a 50%reduction in the SAS area with the use '
of I/A technologies,the local approving authority may grant a local upgrade
approval for reduction to estimated high groundwater in accordance with 310'
CMR 15.405(1)(h).
Approval of SRP WP61a—Certification for Remedial Use Page 4 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
ii. When an applicant chooses up to a two foot reduction in the estimated
separation of high groundwater from the bottom of the SAS area with an I/A
technology, the.local approving authority may consider granting a local upgrade .
approval for SAS reduction in accordance with 310 CMR 15.405(1)(c).
iii. When an applicant chooses a reduction in the naturally occurring soil with the
use of an I/A technology,a local.upgrade approval may grant either a reduction
in.SAS area in accordance with 310 CMR 15.405(1)c or.a reduction in
groundwater separation in accordance with 310 CMR 15.405(1)(h).
B. if any remedial system is,still notable to achieve full compliance with all of the
minimum set back distances in 310 CMR 15.211, even taking into account provisions
for local upgrade approval-in accordance with the provisions of 310 CMR 15.401 —
15.405, the applicant must obtain variance(s)from the approving authority and then
approval from the Department pursuant to 310 CMR 15.410 through filing a BRPWP
59b permit application.
1V. General Conditions
1. All provisions of 310.CMR 15.000 are applicable to the use of this System,the System
owner and the Company, except those that specifically-have been varied by the terms of
this Approval.
2. Any required operation and maintenance,monitoring and testing shall be performed in
.accordance with a Department approved plan.'Any required sample analysis shall be
conducted by an independent U.S.EPA or DEP approved testing laboratory, or a DEP
approved independent university laboratory..It.shall be a violation of this Approval to
.falsify any data collected pursuant to an approved testing plan, to omit any required data
or to,fail to submit any report required by.such plan.
3. The facility served by the System and the System itself shall be open to inspection and
sampling by the Department and the local approving authority at all reasonable times.
4. In accordance with applicable law,the Department and the local approving authoritymay
require the System owner to cease operation of the system and/or to take any other action
as-it deems necessary to.protect public health,"safety, welfare and the environment.
5. The Department las not determined that the performance of the System will provide a
level of protection to public health and safety and the environment that is at least
equivalent to that of a sewer system. No System shall be installed,upgraded or expanded,
if it is feasible to connect the facility to a sanitary sewer,unless as allowed by 310 CMR
15.004. When a sanitary sewer connection becomes feasible,the facility served by the
System shall be connected`to the sewer, within 60 days of such feasibility, and the System
shall be abandoned incompliance with 31`0 CMR 15.354, unless a later time is allowed,in
writing, by the approving authority. ..
6. Design, installation and operation shall be in strict conformance with the Company's DEP
approved plans and specifications, 310 CMR 15.000 and this Approval.
Approval of BRP WP61a—Certification for Remedial Use Page 5 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
V. Conditions Applicable to the System Owner
1. The System is approved for the treatment and disposal of sanitary sewage only. Any
wastes that are non-sanitary sewage generated or.used at the facility served by the System
shall not be introduced into the System and shall be lawfully disposed.
2. Any effluent samples shall be taken at a flowing.discharge point, i.e. distribution box,
pump chamber or other Department approved location downstream of the treatment unit. .
Any required influent sample shall be taken at a point that will provide a representative
sample of the influent. The system designer, subject to written approval by the
Department, shall determine influent.sampling locations.
3. Operation and Maintenance Agreement:
A. Throughout its life,the owner shall operate and maintain the System in accordance
with the Company and designer's operation and maintenance requirements and this
Approval. To ensure proper operation and maintenance(O&M),the owner shall enter
into an O&M agreement.No O&M agreement shall be for less than one year.
B. No System shall be used until an O&M agreement is submitted to the approving
authority which:
i. Provides for the contracting of a person or firm trained by the Company as
provided in Section VI(6)and competent in providing services consistent with
the System's specifications,with the operation and maintenance requirements
specified by the Company and the designer, and with any specified by the
Department;
ii. Contains procedures Tor notification to the Department and the local board of
health withinfive'days of a System failure or alarm event and for corrective
measures to be taken immediately;and
iii. Provides the name of an operator;which must be a Massachusetts certified
operator if one is required by 257 CMR 2,00,that will operate and monitor the
System at least every three months as described in Section II, item 5 and
Section V, item 6, and anytime'there is an alarm event if one is provided.
4. The System owner shall°at all times have the System properly operated and maintained
in accordance with this Approval,the designer's operation and maintenance
requirements and the Company's approved procedures and sampling protocols. The
System owner shall notify the Department and the local approving authority in writing
within seven days of any cancellation;expiration or other change in the terms and/or
conditions of their O&M agreement.
5. Prior to transferring any or all interest in the property served by the System, or any
portion of the property, including any possessory interest,the System owner shall
provide written notice of all conditions contained in this Approval to the transferee(s).
Any and all instruments of transfer and any leases or rental agreements shall include as an
exhibit attached thereto and made a part thereof a copy of this Approval for the System.
The System owner shall send a copy of such written notification(s)to the Department and
local approving authority within 10 days of such notice being given.
Approval of BRP WP61 a—Certification for Remedial Use Page 6 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:x22441 -
6. The System owner shall have the System,monitored quarterly for depth of ponding and
dissolved oxygen(DO) levels in the SAS. Should the System exhibit excessive
ponding levels after three months of operation(water surface elevation equal to or
greater than the water surface elevation prior to installation of the System), at a
minimum, the following parameters shall be„monitored: pH,BOD5, TSS, depth of
effluent and DO in the SAS and water use. Also see Section.I1, item 5 above.
Monitoring shall continue,for at least one year when at the written request of the
System owner,the Department may reduce the monitoring and reporting requirements.
If after IN days of operation,the System is in failure, the System shall be removed in
accordance with Section VI (7).
7. By January 31't of each year for the previous year, the System owner shall submit to
the local approving authority all data collected in accordance with item 6, above,
including all Department Title 5 I/A O&M checklists and System technology
checklists completed during the previous calendar year by the System operator for,each
inspection performed.
8. Prior to the issuance of a Certificate of Compliance for the System, the System owner
shall record and/or register in the appropriate Registry of Deeds and/or Land
Registration Office, a Notice disclosing both the existence of the alternative septic
system subject to this Approval on the property and the Department's approval of the
System. If the property subject to the Notice is unregistered land,the Notice shall be
marginally referenced on the owner's deed to the property. Within 30 days of
recording and/or registering the Notice,the System owner shall submit the following to
the Department and the local approving authority: (i) a certified Registry copy of the
Notice bearing the book and page/instrument number and/or document number;and
(ii) if the property is unregistered land, a Registry copy of the owner's deed to the
property,bearing the marginal reference.
V1. Conditions Applicable to the Company
4..
1. The Company shall develop and submit to.the Department within 60 days of the
effective date of this Approval: minimum site evaluation criteria and installation
-requirements; an operating manual, including information on substances that should
not be discharged to the System; a technology checklist; and a recommended schedule
for maintenance and replacement of the plastic media essential to consistent successful
performance of the installed Systems. The Company shall develop and submit to the
Department within 60 days.of the effective date of this Approval a standard protocol
essential for consistent and accurate measurement of the performance of installed
h.. Systems, including procedures for sampling, collecting data and analysis of the System
eientand fo ffl r evaluating effluent depth in the SAS. The sampling and analysis
protocol.shall be in accordance with the latest edition of Standard Methods for the
" . Exaniination''of Water and Wastewater. The Company shall make available, in print
j and electronic format,the referenced procedures and protocol above to owners,
n
operators, designers and installers ofthe System. The Company shall submit to the.
Department within 60 days of the effective date of this Approval a complete manual on
operation of the SAS monitoring unit and the procedures required to conduct
Approval of BRP WP61 a—Certification for Remedial Use Page 7 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
monitoring of the System and any procedures that will be implemented should the
monitoring System fail. -
2. By February 15`l'of each year,the Company shall submit a report to the Department,
signed by a corporate officer, general partner or Company owner that contains
information on the System, for the previous calendar year. The report shall include the
following information:
A. The total number of units of the System sold for use in Massachusetts during the
previous year;the address of each installed System,the owner's name and
address,the type of use(e:g. residential,commercial,institutional)and the design
flow; -
B. Date when system was installed and started up;
C. Tabulation of tfie sampling.parameters and results with backup inspection and
laboratory sheets;
D. Statistical analysis of the sampling results including but not limited to average and
mean values; status of the SAS including depth of effluent and change in depth-x
over the operating year;
E. Tabulation of systems that are in failure,as described in 310 CMR 15.303
(1)(a)(1)or(2)due to excessive ponding of effluent in the SAS, reasons for non-
compliance and any corrective action taken including but not limited to design,
installation and/or operation or maintenance changes required to reach
compliance;
F. The inspection results recorded on a Department approved inspection form and a
technology checklist. The forms must be completed by the System operator and
submitted to the Department with the annual report.
G. A general summary of the results for the year, any recommended changes to the.,
design, installation and/or operation and maintenance procedures and a schedule
for implementing those changes;and
H. Warranty issues both resolved and unresolved or an explanation of any warranty
claims that have been received and their resolution.
3. The Company or its designee shall review the plansand site evaluation conducted for
the System prior to the sale of any unit to ensure that the proposed installation of the
System is at a site consistent with this Approval and the System's capabilities. The
Company shall certify in writing that the System plan and existing site conditions
conform to the requirements of this Approval and any requirements of the Company
and shall submit a copy of that certification tothe•local approving authority and the
System owner. .
4. Prior to the issuance of a Certificate of Compliance for the System,the Company shall
submit to the local approving authority and the System owner a signed certification that
the System has been installed in accordance with the'Company's requirements,the
approved plan and this Approval. This certification in no way changes the requirements
of 310 CMR 15.021(3).
Approval of BRP WP61a—Certification for.Remedial Use - Page 8 of 10
Aero-Stream Aerobic Septic System Restoration Process .'
Transmittal NumberA22441 ,
5: The Company or the Company's approved operation and maintenance contractor shall
maintain a contract with.the,System owner`that:
A. .Provides for operating and'maintaming the System with an operator that has been ..:
trained by the Company to operate,the,System consistent with the System's
specifications and any additional operation and maintenance requirements
specified by the designer or by"the Department;
3. ...Contains procedures for notification to the:System owner,the Department and the
local approving authority`within fiveAays of knowledge of a System failure and
for corrective measures to be taken immediately;
C. Contains procedures for inspecting the plastic media bacterial source at each
quarterly visit and if necessary replacing the media. At a minimum,the microbial
inoculants shall be replaced annually; and
D.•..-Contains a'plan to determine if required afterfthe first three months of operation
w•hy the effluent water,.surface ele`vations•in the SAS are as high or higher then the
water surface elevation when the System.was installed. ,
6. The Compdq,shall institute and maintain a—program of operator training and
continuing education,asapproved bythe Deparfrrient. The Company.shall maintain
and:annually update,and-make the;list of qualified operators available by February 1 S`
of each-year!'The company shall update the-list of qualified operators and make the'list r
known to users of-the technology: .T V
7. The Company shall provide to each Systerrl,owner,'a written warranty transferable to a J
new owner that includes the'following:'
A Refund of.the cost of equipment and installation should the System continue in;
failure.as descnbed;in 310.CMR`15.303(1)(a)(1')and (2) after'120 days of
operation that]s'conduc:ted.in accordance with the Company's specifications and;
oversight; or'
13 , Refund of the cost of equipment and installation should the System sail as
'described in.310.CMR 15.303(1)(a)(t1)slid(2).within two years of installation
provided'thatthe System owner has'entered into'arid maintained an operationand
:maintenance contract with the Company and has'operated the System in
accordance with the.Company's specifications. "
8. The Company shall conduct a performance evaluation starting after the first 100
systems Have'been installed and operating for at least one year. A report shall be
submitted to the Department no more than.180 days beyond the one year period
g percent of the units installed for at least one year have
ad
evaluating whether at least 90
demonstrated a reduc#lon.;ln depth(data as requlred'.in;Sections II; items and V, item
6)and thatthe�reductlon in depth of the effluent elevation for the SAS systems has ,
occurred within 120 days of start up or that ponding elevations are not excessive.
Should the System not demonstrate the capability to reduce or eliminate ponding in 90 '
percent of the failed systems,the report shall Akail the changes that must be made in.,'
site evaluation,design, installation and/or operation or maintenance to meet the goal
and shall include a schedule con_taining a deadline for.iniplementing those changes. No
more than 100',systems`'shall be installed until the,performance report has been
3 .
Approval of BRP WP61a—Certification for Remedial Use Page 9 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
completed and the results indicate that over 90.percent of the Systems are no longer in
failure.
9. The Company shall include copies of this Approval and the procedures and protocol
described in Section VI 1 with each System that is sold. In an contract executed b
( ). Y Y Y
the Company for distribution or re=sale of the System,the Company shall require the
distributor or re-seller to provide each purchaser of the System with copies of this
Approval and the procedures and protocol described in Section VI(1).
10. The Company shall notify the Director'of the Wastewater Management Program at
least 30 days in advance of the proposed transfer of ownership of the technology for
which this Approval issued. Said notification'shall include the name and address of the
proposed new owner and a written agreement between the existing and proposed new
owner containing a specific date for transfer of ownership,responsibility, coverage and
liability between them. All provisions of this Approval applicable to the Company
shall be applicable to successors and assigns of the Company,unless the Department
determines otherwise.
11. The Company shall furnish the Department any information that the Department
requests regarding the System within 21 days of the receipt of that request.
12. If the Company wishes to continue this Approval after its expiration date,the Company
shall apply for and obtain a renewal of this Approval. The Company,shall submit a
renewal application at least 180 days before the expiration date of this Approval,unless
written permission for a later date has-been granted in writing by the Department. This
approval shall continue.in force until the Department has acted.on the renewal
application.
VII. Reporting
1. All notices and documents required to be submitted to the Department by this Approval
shall o be submitted to:
Director
Wastewater Management Program
Department of Environmental Protection
One Winter Street-5th floor
Boston,Massachusetts 02108
VIII. Rights of the Department
1. The Department may suspend,modify or revoke this Approval for cause,including,but
not limited to, non-compliance with the terms of this Approval,non-payment of the
annual compliance assurance fee, for obtaining the Approval by misrepresentation or
failure to disclose fully all relevant'facts or any change in or discovery of conditions that
would constitute grounds for discontinuance of the Approval, or as necessary for the
protection of public health, safety,welfare or the environment, and as authorized by
applicable law. The Department reserves its rights to take any enforcement action
authorized by law with respect to this Approval and/or the System against the owner,or
operator of the System and/or the Company.
f .
Approval of BRP WP61a—.Certification for Remedial Use Page 10 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
IX. Expiration Date
l. Notwithstanding the expiration date of this Approval, any System sold and installed prior
to the expiration date of this Approval, and approved, installed and maintained in
compliance with this Approval(as it may be modified)and 310 CMR 15.000, may
remain in use unless the Department,the local approving authority, or a court requires the
System to be modified or removed,or requires discharges to the System to cease.
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9. The Operator.shallmonitor the System quarterly for depth of ponding and dissolved
oxygen (DO) levels in the SAS.Should the System exhibit excessive ponding levels
after three months-of operation (water surface elevation equal to or greater than the
water surface elevationprior toinstallation.of.the System), at a minimum, the
following parameters shall be monitored: pH;BODS, TSS, depth of effluent and DO in
the.SAS and water use:,The system owner will be responsible for certified laboratory `
testing fees at competitive rates as well as costs associated with water usage
monitoring as required.Also see Section II, item 5 of the approval.
10. Monitoring{shall continue for at least one year,when at the written request of the
System owner, the Department may reduce the monitoring and reporting
requirements. If after 120.days of operation, the System is in failure, the System shall
be removed in accordance with Section VI (7)of the approval.
11. By January-31"of each year for the previous year, the System owner sha_ll°submit to
the local approving authority all data collected in accordance with item 9, above,
including 611.Department Title 5 I/A O&M checklists and System technology checklists
completed during the previous calendar year by the System operator for each
inspection performed.
12. Prior to the issuance of a Certificate of Compliance for the System, the System owner
shall record and/or register in the appropriate Registry of Deeds and/or Land
Registration Office, a Notice disclosing both the existence of the alternative septic
system subject to this Approval on the property and the Department's approval of the
System. If the property subject to the Notice is unregistered land, the Notice shall be
marginally referenced on the owner's deed to the property. Within 30 days of
recording and/or registering the Notice, the System owner shall submit the following
to the Department and the local approving authority: (i)a certified Registry copy of
the Notice bearing the book and page/instrument number and/or document number;
and (ii) if the property is unregistered land, a Registry copy of the owner's.deed to the .Y
property, bearing the marginal reference.
have read and agree to the terms of this agreement:
Owner: _ Operator:
Date: Date:
A co of this`executed~document must be provided to the local
copy
approving authority and Aero-Stream®, LLC.
2of2
Aero-Stream®,LLC
W300 N7706 Christine Lane Hartland,WI 53029
262.538.4000-Fax:262.538.4093
Web:w\Fi aero-stream.com
SAAero-Stream\State ApprovaRMA Maintenance Agreement.doc
ry: T�E 4 Town of Barnstable
of tphy - Barnstable
Board -of Health . A&AmedcaCity
RARNSYABLE, ` -
r HAss. 200 Main Street,Hyannis.MA 02601 m�
ppA 03;
2007
Office: 508462-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Junichi Sawayanagi
Paul Canniff,D.M.D.
Mr. David J. Burnie January 28, 2011
3 Perry s Way
Harwich , MA 02645
RE: 53 Uncle Willies Road, Hyannis/ Installation,of Aero-Stream Aerobic
Septic"System Restoration Equipment
-Dear Mr. Burnie -
You are granted permission to install restoration equipment (Trade name: Aero-,
Stream Aerobic Septic System Restoration;Process) at 53 Uncle Willies Road,
Hyannis, Massachusetts:'
1) The applicant must obtain a disposal works construction permit. During,the.
application process, the applicant shall submit the following: (a) copy of the
as-built card, (b) diagrafn of the proposed unit to be installed, (c) copy of
the DEP approval.letter, (d) approved monitoring plan, (e) completed
disposal works constructionpermit application form,sand (f) payment of the
required permit application fee.
2) Monitoring and testing shall be performed in quarterly for pH, BOD5, TSS,
depth of effluent, and DO in the SAS during the first two years of operation
and after that time period, the applicant may request a reduction upon ,
review of the testing information during a public Board meeting. Sample
analysis shall,be conducted by an independent US EPA or DEP approved
testing.laboratory, or a DEP approved,independent university laboratory.
Effluent.samples shall be taken at a flowing discharge point.
3) The system owner shall also have the system monitored quarterly for depth
of ponding.
This permission is granted because the existing septic system is in failure. Mr. David
J. Burnie, the:applicant, has been trained in the use of Solinist Levelogger and
Barologger equipment', according,to Don,Burcham of Aero-stream LLC.
Sincerely yours
Wayne Miller,,M.
ChairmaU
Q:\WPFILES\IA Aeration 53 Uncle Willies.doc
�T
Town of-Barnstable
OFt�tDly. Barnstable
Board of Health AFftWeaCitv
MASS. �. 200 Main Street, Hyannis MA 02601 t O D
s63p. �0
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Junichi Sawayanagi
Paul Canniff,D.M.D.
Mr. David J. Burnie January 28, 2011
3 Perry's Way
Harwich , MA 02645
RE: ,53 Uncle Willies,Road; Hyannis/ Installation of Aero-Stream Aerobic
Septic System Restoration.Equipment
Dear Mr. Burnie;
You are granted permission to install restoration equipment (Trade name: Aero-
Stream Aerobic Septic System Restoration'Process) at 53 Uncle Willies Road,
Hyannis, Massachusetts:
1) The applicant must obtain a disposal works construction permit. During the
application process, the applicant shall.submit the following: (a) copy of the
as-built card, (b) diagram of the proposed unit to be installed, (c) copy of
the DEP approval letter, (d) approved monitoring plan, (e) completed
disposal works construction per application form, and (f) payment of the
required permit application fee:
2) Monitoring and testing shall be performed in quarterly for pH, BOD5, TSS
depth of effluent, and DO in the SAS during the first two years of operation
and after that time period, the applicant may request a reduction upon
review of the testing information during a public Board meeting. Sample
analysis shall be conducted by'an independent US EPA or DEP approved
testing laboratory, or a DEP approved independent university laboratory.
Effluent samples shall be taken at a,flowing discharge point.
3) The system owner shall also have thesystem monitored quarterly for depth
of ponding.
This permission is granted`because the existing septic system is in failure. Mr. David
J. Burnie, the applicant, has been trained in the use of Solinist Levelogger and.
Baro gger equipment, according to Don Burcham of Aero-stream LLC.
Sin a ely you
lk q
A/
Walyne it r, D.
Chairm
Q:\Si \IA Aeration Tdd.doc
KS �G9 L`
6- 1
fy
David J. Burnie Management, Inc.
3 Perry's Way
Harwich, MA 02645
508-432-0223 -1-866-980-1440
- -Fax 508-430-1450
i
Barnstable Board of Health
200 School Street
. t
Hyannis,MA 02601
December 21,2010
Y .
Refereno .i°3dCTncle_W�ll es7Raad H-Yann�s;MA* , '
.__ _
On December 17,2010,David J. Burnie Management,Inc.responded to a septic
backup at the above referenced address.
I observed the following: -
1. The septic tank was overfull.
2.-During pumping we had an estimate of five hundred gallons runback from the
leaching area.
3. We performed a Title V inspection and found the system to be in a state of failure
and submitted it to the health department
I discussed this with Mr.Thomas Mc Kean and we did an emergency repair using the
Aero-StreamR remediation process. I look forward to your.January 1.1,2011 meeting to
discuss this procedure with the Barnstable Board of Health and to hopefully receive
permission to continue to offer the-Aero--SLTeaMR:process:to other.property owners.
Respectfully Submitted,
zavidBurnie zft
General Manager ; ' =
Licensed Installer and;Certified Title V Inspector.SI#386 `T
DJB/rmb
4
; 0. tit,
6/7/10
Don Burcham
Sales and Technical Support
Aero-Stream® LLC
To Whom It May Concern:
The David J Burnie Mgmt, Inc. is an authorized installer of the Aero-Stream®
equipment. His company has the ability to install and maintain our units in all
residential and commercial applications. His company has been trained in the
use of the Solinst Levelogger and Barologger equipment. His company has the
software to collect the needed quarterly information from the installed units.
Sincerely
Don Burcham
877-254-7093 f
W300 N7706 Christine Lane Hartland,Wl
262-638-4000
www.aero-stream.com info@aero-stream.com
k ..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENERGY& ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
DEVAL L.PATRICK IAN A.BOWLES
Governor Secretary
TIMOTHY P.MURRAY LAURIE BURT
Lieutenant Governor
. ,, , Commissioner
APPROVAL FOR REMEDIAL USE
Pursuant to Title, 310-CMR 15.000
Name and Address of Applicant: ;
Aero=Stream; LLC
W300 N7706 Christine Lane
Hartland, WI 53029
Trade name of technology: Aero-Stream Aerobic Septic System Restoration Process Models QT
800HMA, 800HHMA, 800UHMA and 800EHMA(hereinafter called the"System"). Schematic .,
drawing of a typical System and Technology checklist are attached and are a part of this
Approval.
Transmittal Number: X22441
Date of Issuance: January 27, 2009 °
Expiration dater January 27, 2014
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000,the Department of
Environmental Protection hereby issues this Approval for Remedial Use to: Aero-Stream, LLC
W300 N7706 Christine Lane, Hartland,WI 53029 (hereinafter"the Company"), approving the
System described herein for Remedial Use in the Commonwealth of Massachusetts. Sale and use
of the System are conditioned on compliance by the Company and the System owner with the
terms and conditions set forth below. Any noncompliance with the terms or conditions of this
Approval constitutes a violation of 310 CMR 15.000.
- Januar 227,2009
enn Haas, kc ingAssistant Commissioner Date
Bureau of Resource Protection
This information is available in alternate format.Call Donald A1.Gomel,ADA Coordinator at 617-556-1057.TDD#1-866-539-7622 or 1-617-574-6868.
MassDEP on the World Wide Web: http://www.mass.gov/dep
L0 Printed on:Recycled Paper
Approval of BRP WP61a—Certification for Remedial Use Page 2 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
. .
1. Purpose
1. The purpose of this Approval is to allow use of the System in Massachusetts,on a
Remedial Use basis to repair systems failing to protect public health and safety and the
environment where failure has occurred as described in 310 CMR 15.303 (1) (a) (1)and
(2)due to clogging of the soil,absorption system(SAS).
2. With the necessary permits and approvals required by 310 CMR 15.000,this Approval
for Remedial Use authorizes the use and installation of the System in Massachusetts.
3. The System may only,be installed on facilities that meet the criteria of 310 CMR
15.284(2).
4. This Approval for Remedial Use authorizes the use of the System where the local
approving authority finds that the System is for upgrade of a failed, failing or
nonconforming system and the design flow"for the facility is less than 2,000 gallons per
day (GPD)..
II. Design Standards
1. The System is designed to convert an anaerobic system into an aerobic system and reduce the
strength of the wastewater received by the existing soil absorption system(SAS).Prior to
System installation the septic tank must be pumped to remove settled solids. The System
consists of an Aero-Stream'aeration unit, i 20 volts operated on a continuous basis,with an
airline piped into an existing septic tank or a new septic tank designed in accordance with
310 CMR 15.223 through 15.228. The airline feeds a Micro Bubble Diffuser with floats
within the septic tank. The adjustable floats are connected to the airline and keep the diffuser-
suspended at the proper level•inthe tank,typically 18 inches from the bottom.
2. Aerobic treatment is established in the septic tank and maintained using the Aero-Stream
aeration unit. The aerator mixes the contents of the septic tank with the bacteria and aerates
the wastewater.The System's biomass reduces the strength of the wastewater in the septic
tank.The aerated effluent from the septic tank is designed to reduce the thickness of the
existing biomat in the.SAS,thereby improving the soil absorption capacity.
3. Prior to installation of the System,the site shall be evaluated in accordance with 310 CMR
15.100 through 15.107. The existing on-site system including the septic tank,distribution
box and SAS shall be inspected in accordance with 310 CMR 15.302.
4. The System shall not be proposed for installation where:
A. The`high groundwater elevation determined in accordance with 310 CMR 15.103 ,
would be less than two feet below the bottom of the SAS.
B. A facility for which the site investigation indicates that the existing onsite system was
designed and installed for a design flow smaller than required by 310 CMR 15.203.The
minimum area for the existing SAS shall not be less than 50 percent of the area required'
in accordance with 310 CMR 15.242.
Approval of BRP WP61a—Certification for Remedial Use Page 3 of 10
Aero-Stream Aerobic Septic System Restoration.Process
Transmittal Number:X22441
C. The existing septic tank(s)has not been tested and shown to be watertight.
D. The proposed installation is for a failed or failing leaching pit or cesspool.
E. A site investigation indicates that the existing soil absorption system must be removed
and replaced prior to installation of the System.
5. The System shall be equipped with'a monitoring device that provides data collection to
include tracking the elevation of the effluent in the SAS,and temperature.The data can be
stored and reported to include high,low and average levels for each parameter each month
and daily values for the last thirty days.
6. For seasonal use,the System operator shall witness reactivation of System at each start-up
and ensure System monitoring is recording'properly.
III. Allowable Soil Absorption System Design
l. The following reductions are allowable when evaluating the System:
A. The approving authority may allow up to a 50 percent reduction in the existing soil
absorption system required by 310 CMR 15.242; or
B. The approving authority may allow a reduction in the required separation between
the bottom of the SAS and the high groundwater elevation of up to two feet. This
provides a minimum separation of two feet(in soils with a recorded percolation rate
of more than two minutes per inch)or three feet(in soils with a recorded percolation
rate of two minutes or less per inch);or
C. The approving authority may allow a reduction in the required four feet of naturally
occurring pervious material in an area with no less than two feet of naturally
occurring pervious material,provided that it has been demonstrated that the four
foot requirement cannot be met anywhere on the site.
EXCEPTION: If a remedial System needs more than one of the allowable reductions
listed above, then the'reductions must first be approved"by the local approving authority
and then approved by the Department pursuant to 310 CMR 15.284 through filing a
BRPWP 64c permit application.
2. Additional reductions allowable when evaluating-the System:
A. When using 1A, 1B, or I above for the System where full compliance with 310 CMR
15.000 is not feasible, the local approving authority may consider granting local
upgrade approvals in accordance with the provisions of 310 CMR 15.401 — 15.405.
For example:
i. •When an applicant chooses up to a 50%reduction in the SAS area with the use
of UA technologies,the local approving authority may grant a local upgrade
approval for reduction to estimated high groundwater in accordance with;310
CMR 15.405(1)(h).
0.
Approval of BRP W P61a—Certification for Remedial Use Page 4 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
ii. When an applicant chooses up to a two foot reduction in the estimated
separation of high groundwater from the bottom of the SAS area with an I/A
technology, the local approving authority may consider granting a local upgrade
approval for SAS reduction in accordance with 310 CMR 15.405(1)(c).
iii. When an applicant chooses a reduction in the naturally occurring soil with the
use of an I/A technology, a local upgrade approval may grant either a reduction
in SAS area in accordance with 310 CMR 15.405(1)c or a reduction in
groundwater separation in accordance with 310 CMR 15.405(1)(h).
B. if any remedial system is still not able to achieve full compliance with all of the
minimum set back distances in 310 CMR 15.211, even taking into account provisions
for local upgrade approval in accordance with the provisions of 310 CMR 15.401 —
15.405, the applicant must obtain variance(s)from the approving authority and then
approval from the Department pursuant to 310 CMR 15.410 through filing a BRPWP
59b permit application.
1V. General Conditions
1. All provisions of 310 CMR 15:000 are applicable to the use of this System,the System
owner and the Company, except those that specifically have been varied by the terms of '
this Approval.
2. Any required operation and maintenance,monitoring and testing shall be performed in
accordance with a Department approved plan. Any required sample analysis shall be
conducted by an independent U.S.EPA or DEP approved testing laboratory,or a DEP
approved independent university laboratory. It shall be a violation of this Approval to
falsify any data collected pursuant to an approved testing plan, to omit any required data
or to fail to submit any report required by such plan.
3. The facility served by the System and the System itself shall be open to inspection and -
sampling by the Department and the local approving authority at all reasonable times.
4. In accordance with applicable law,the Department and the local approving authority may
require the System owner to cease operation of the system and/or to take any other action
as it deems necessary to protect public hcalth, safety, welfare and the environment.
5. The Department has not determined that the performance of the System will provide a
level of protection to public health and safety and the environment that is at least
equivalent to that of a sewer system. No System shall be installed,upgraded or expanded,
if it is feasible to connect the facility to a sanitary sewer,unless as allowed by 310 CMR
15.004. When a sanitary sewer connection becomes feasible,the facility served by the
System shall be connected to the sewer, within 60 days of such feasibility, and the System
shall be abandoned in compliance with 310 CMR 15.354, unless a later time is allowed, in
writing,by the approving authority.
6. Design, installation and operation shall be in strict conformance with the Company's DEP
approved plans and specifications, 310 CMR,15.000 and this Approval.
i
Approval of BRP WP61a—Certification for Remedial Use Page 5 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
V. Conditions Applicable to the System Owner
1. The System is approved for the treatment and disposal of sanitary sewage only. Any
wastes that are non-sanitary sewage generated or used at the facility served by the System
shall not be introduced into.the System and shall be lawfully disposed.
2. Any effluent samples shall be taken at a flowing discharge point, i.e. distribution box,
pump chamber or other Department approved location downstream of the treatment unit.
Any required influent sample shall betaken at a point that will provide a representative
sample of the influent. The system designer,subject to written approval by the
Department, shall determine_influent sampling locations. „
ti
3. Operation and Maintenance Agreement:
A. Throughout its life,the owner shall operate"and maintain the System in accordance
with the Company and designer's operation and maintenance requirements and this
Approval. To ensure proper operation.and maintenance(O&M),the owner shall enter
into an O&M agreement.No O&M agreement shall be for less than one year.
B. No System shall be used until an O&M agreement is submitted to the approving
authority which:
i. Provides for the contracting of a person or firm trained by the Company as
provided in Section VI(6)and competent in providing services consistent with
the System's specifications,with the operation and maintenance requirements
specified by the Company and the'designer, and with any specified by the
Department;
ii. Contains procedures for notification to the Department and the local board of
health within five days of a System failure or alarm event and for corrective
measures to be taken immediately;,and
iii. Provides the name of an operator,which must be a Massachusetts certified
operator if one is required by 257 CMR 2.00,that will operate and monitor the
System at least every'three months as described in Section II, item 5 and
Section V,item 6, and anytime there is an alarm event if one is provided.
4. The System owner shall at all times have the System properly operated and maintained
in accordance with this Approval,the designer's operation and maintenance
requirements and the Company's approved procedures and sampling protocols. The
System owner shall notify the Department and the local approving authority in writing
within seven days of any cancellation,expiration or other change in the terms and/or
conditions of their O&M agreement.
5. Prior to transferring any or all interest in the property served by the System, or any
portion of the property,including any possessory interest,the System owner shall
provide written notice of all conditions contained iii this Approval to the transferee(s).
Any and all instruments of transfer and any leases or rental agreements shall include as an
exhibit attached thereto and made a part thereof a copy of this Approval for the System.
The System owner shall send a copy of such written notification(s)to the Department and
local approving authority within 10 days of such notice being given.
Approval of BRP WP61a—Certification for Remedial Use Page 6 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:x22441
6. The System owner shall have the System monitored quarterly for depth of ponding and
dissolved oxygen(DO) levels in the SAS. Should the System exhibit excessive
ponding levels after three months of operation(water surface elevation equal to or
greater than the water surface elevation prior to installation of the System), at a
minimum, the following parameters shall be monitored: pH,BOD5, TSS, depth of
effluent and DO in the SAS and water use. Also see Section II, item 5 above.
Monitoring shall continue for at least one year when at the written request of the
System owner,the Department may reduce the monitoring and reporting requirements.
If after 120 days of operation,the System is in failure, the System shall be removed in
accordance with Section VI(7).
7. By January 31't of each year for the previous year,the System owner shall submit to
the local approving authority,all data collected in accordance with item 6, above,
including all Department Title 5 I/A O&M checklists and System technology
checklists completed during the previous calendar year by the System operator for each ,
inspection performed.
8. Prior to the issuance of a Certificate of Compliance for the System,the System owner
shall record and/or register in the appropriate Registry of Deeds and/or Land
Registration Office,a Notice disclosing both the existence of the alternative septic
system subject to this Approval on the property and the Department's approval of the
System. If the property subject to the Notice is unregistered land,the Notice shall be
marginally referenced on the owner's deed to the property. Within 30 days of
recording and/or registering the Notice,the System owner shall submit the following to
the Department and the local approving authority: (i) a certified Registry copy of the
Notice bearing the book and page/instrument number and/or document number; and
(ii) if the property is unregistered land, a Registry copy of the owner's deed to the
property,bearing the marginal reference.
Vl. Conditions Applicable to the Company _
1. The Company shall develop and submit to the Department within 60 days of the
effective date of this Approval: minimum site evaluation criteria and installation
requirements; an operating manual, including information on substances that should
not be discharged to the System; a technology checklist; and a recommended schedule
for maintenance and replacement of the plastic media essential to consistent successful
performance of the installed Systems. The Company shall develop and submit to the '
Department within 60 days of the effective date of this Approval a standard protocol
essential for consistent and accurate measurement of the performance of installed
Systems, including procedures for sampling,collecting data and analysis of the System
effluent and for evaluating effluent depth in the SAS. The sampling and analysis
protocol shall be in accordance with the latest edition of Standard Methods for the
Examination of Water and Wastewater. The Company shall make available, in print
and electronic format,the referenced procedures and protocol above to owners,
operators;designers and installers of the System. The Company shall submit to the
Department within 60 days of the effective date of this Approval a complete manual on
operation of the SAS monitoring unit and the procedures required to conduct
Approval of BRP WP61a—Certification for Remedial Use Page 7 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
monitoring of the System,and any procedures that will be implemented should the
monitoring System fail.
2. By February 150'of each year,the Company shall submit a report to the Department,
signed by a corporate officer, general partner or Company owner that contains
information on the System, for the previous calendar year. The report shall include the
following information:
A. The total number of units of the System sold for use in Massachusetts during the
previous year;the address of each installed System,the owner's name and
address,the type of use(e.g. residential,commercial, institutional) and the design
flow;
B. Date when system was installed and started up;
C. Tabulation of tfie sampling parameters and results with backup inspection and
laboratory sheets;
D. Statistical analysis of the sampling results including but not limited to average and
mean values; status of the SAS including depth of effluent and change in depth
over the operating year;
E. Tabulation of systems that are in failure as described in 310 CMR 15.303
(1)(a)(1) or(2)due to excessive poriding of effluent in the SAS,reasons for non-
compliance and any corrective action taken including but not limited to design,
installation and/or operation or maintenance changes required to reach
compliance; `
F. The inspection results recorded on a Department approved inspection form and a
technology checklist. The,forms must be completed by the System operator and
submitted to the Department with the annual report. -.
G. -A general summary of the results for the year, any recommended changes to the
design, installation and/or operation and maintenance procedures and a schedule "
for implementing those changes; and
H. Warranty issues both resolved and unresolved or an explanation of any warranty
claims that have been received and their resolution.
3. The Company or its designee shall review the plans and site evaluation conducted for
the System prior to the sale of any unit to ensure that the proposed installation of the
Y System is at a site consistent with this Approval and the System's capabilities. The
Company shall certify in writing that the System plan and existing site conditions
conform to the requirements of this Approval and any requirements of the Company
and shall submit a copy of that certification to the local approving authority and the
System owner. _
4.. Prior to the issuance of a Certificate of Compliance for the System,the Company shall
submit to the local approving authority and the System owner a signed certification that
the System has been installed in accordance with the Company's requirements,the `
approved plan and this Approval.This certification in no way changes the requirements
of 310 CMR 15.021(3). '
Approval of BRP WP6la—Certification for Remedial Use Page 8 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
5. The Company or the Company's approved operation and maintenance contractor shall
maintain a contract with the System"owner that:
A. Provides for operating and maintaining the System with an operator that has been
trained by the Company to operate the System consistent with the System's
specifications and any,additional operation and maintenance requirements
specified by the designer or by the Department;-
B. Contains procedures for notification to the System owner,the Department and the
local approving authority within five days of knowledge of a System failure and
for corrective measures to be taken immediately;
C. Contains procedures for inspecting the plastic media bacterial source at each
quarterly visit and if necessary replacing the media. At a minimum,the microbial
inoculants shall be replaced annually; and
D. Contains a plan to determine if required after the first three months of operation
why the effluent water surface elevations in the SAS are as high or higher then the
water surface elevation when the System was installed.
6. The Company shall institute and maintain a program of operator training and
continuing education, as approved by'the Department. The Company shall maintain
and annually update, and make the list of qualified operators available by February 1"
of each year. The company shall update the list of qualified operators and make the list
known to users of the technology.
7. The Company shall provide to each System owner a written warranty transferable to a
new owner that.includes the following:"
A. Refund of the cost of equipment and installation should the System continue in
failure.as described in 310 CMR 15.303(1)(a)(1)and (2)after 120 days of
operation that is conducte&in accordance with the Company's specifications and
oversight; or
f
B. Refund of the cost of equipment and installation should the System fail as
"described in 310 CMR 15.303(l)(a)(1) and(2)within two years of installation
provided that the System owner has entered into and maintained an operation and
maintenance contract with the Company and has operated the System in
accordance with the Company's specifications.
8. The Company'shall conduct a performance evaluation starting after the first 100
systems have been installed and operating for at least one year. A report shall be
submitted to the Department no more than 180 days beyond the one year period
evaluating whether at least 90 percent of the units installed for at least one year have
demonstrated a reduction in depth(data as required in Sections II, item 5 and V, item
6) and that the reduction in depth of the effluent elevation for the SAS systems has
occurred within 120 days of start up or that ponding elevations are not excessive.
Should the System not demonstrate the capability to reduce or eliminate ponding in 90
percent of the failed systems,the report shall detail the changes that must be made in
site evaluation, design, installation and/or operation or maintenance to meet the goal
and shall include a schcdule containing a deadline for implementing those changes. No
more than 100 systems.shall be installed until the performance report has been
f
Approval of BRP WPbla—Certification for Remedial Use Page 9 of 10
Aero-Stream Aerobic Septic System Restoration Process
Transmittal Number:X22441
completed and the results indicate that over 90 percent of the Systems are no longer in
failure.
9. The Company shall include copies of this Approval and the procedures and protocol
described in Section VI (1)with each System that is sold. In any contract executed by
the Company for distribution or re-sale of the System,the Company shall require the
distributor or re-seller to provide each purchaser of the System with copies of this
Approval and the procedures and protocol described in Section VI(1).
10. The Company shall notify the Director of the Wastewater Management Program at
least 30 days in advance of the proposed transfer of ownership of the technology for
which this Approval issued. Said notification shall include the name and address of the
proposed new owner and a written agreement between the existing and proposed new
owner containing a specific date for transfer of ownership,responsibility, coverage and
liability between them. All provisions of this Approval applicable to the Company
shall be applicable to successors and assigns of the Company, unless the Department
determines otherwise.
11. The Company shall furnish the Department any information that the Department
requests regarding the System within 21 days of the receipt of that request.
12. If the Company wishes to continue this Approval after its expiration date,the Company
shall apply for and obtain a renewal of this Approval. The Company shall submit a
renewal application at least 180 days before the expiration date of this Approval,unless
written permission for a later date has been granted in writing by the Department. This
approval shall continue in force until the Department has.acted on the renewal
application.
VII. Reporting
1. All notices and documents t=equired to be submitted to the Department by this Approval-
shall be submitted to:
Director
Wastewater Management Program
Department of Environmental Protection
One Winter Street-5th floor
Boston, Massachusetts 02108
VIII. Rights of the Department
1'. The Department may suspend,.modify or revoke this Approval for cause,including,but
not limited to,non-compliance with the terms of this Approval,non-payment of the
annual compliance assurance fee, for obtaining the Approval by misrepresentation or
failure to disclose fully all relevant facts or any change in or discovery of conditions that
would constitute grounds for discontinuance of the Approval, or as necessary for the
protection of public health,.safety,.welfare or the environment, and as authorized by
applicable law. The Department reserves its rights to take any enforcement action
authorized by law with respect to this Approval and/or the System against the owner,or 1
operator of the System and/or the Company.
Approval of BRP WP61a—Certification for Remedial Use Page 10 of 10
Aero-Strea
m Aerobic Septic System Restoration Process
Transmittal Number:X22441
IX. Expiration Date
1. Notwithstanding the expiration date of this Approval,any System sold and installed prior
to the expiration date of this Approval, and approved, installed and maintained in
compliance with this Approval (as it may be modified)and 310 CMR 15.000, may
remain in use unless the Department, the local approving authority, or a court requires the
System to be modified or removed,or requires discharges to the System to cease.
t
INSTALLATION DIAGRAM
AFRO-STREAM®
FLOATS UNIT
+B•i
-.ten..
y .r
s Y
:FROM .HOUSE BUBBLE PATH -RISER
31- 4' SLACK
SANITARY TEE
to
OUTLET BAFFLE
SANITARY TEE
INLET BAFFLE u
EFFLUENT FILTER
TO FIELD, DRY
' WELL (SEEPAGE
BIO-BRUSHTM PIT), OR MOUND
SINTERED DIFFUSER
TABLE 4 TABLE 4 SLUDGE
COLUMN "A" . COLUMN ' B
FIGURE 5
e
—Vgy Y rw.xtr�t4 - -- .. �-_ ..ten.•oe.u.� _ _
77
,T
ASK
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OVA
MA
OPERATING & MAINTENANCE AGREEMENT
This agreement is binding between the"Owner"of the system and SAS (soil absorption system) `
and authorized"Operator"responsible for the operating and maintenance of the system, SAS,
and Aero-Stream®equipment as listed below.
Owner: Operator:
Address: Address:
1. Throughout its life, the owner shall operate and maintain the System in accordance with
the Company and designer's operation and maintenance requirements and the MA DEP
, k
"Approval".
2. This O&M agreement shall be for one year.
3. No System shall be used until this O&M agreement is submitted to the approving
authority.
4. Operator must notify the Department and the local board of health within five days of
a System failure and for corrective measures to be taken immediately; and
The operator will monitor the System at least every three months as described in the
approval Section II, item 5 and Section V, item 6, and anytime there is a system
failure.
6. The System owner shall at all times have the System properly operated and
maintained in accordance with the Approval,the designer's operation and
maintenance requirements and the Company's approved procedures and sampling
protocols.
7. The System owner shall notify the Department and the local approving authority in
writing within seven days of any cancellation,.expiration or other change in the terms
and/or conditions of this agreement.
8. Prior to transferring any or all interest in the property served by the System, or any
portion of the property, including any possessory interest, the System owner shall
provide written notice of all conditions contained in this Approval to the transferee(s).
Any and all instruments of transfer and any leases or rental agreements shall include as
an exhibit attached thereto and made a part thereof a copy of this Approval for the
System. The System owner shall send a copy of such written notification(s)to the
Department and local approving authority within 10 days of such notice being given.
' r
1 of 2
Aero-Stream®,LLC
W300 N7706 Christine Lane Hartland,WI 53029
262.538.4000-Fax:262.538.4093
Web:www.aero-stream.com
S:\Aero-Stream\State ApprovaRMA Maintenance Agreement.doc
J
k { � P
9. The Operator shall monitor the System quarterly for depth of ponding and dissolved
oxygen (DO) levels in the SAS. Should the System exhibit excessive ponding levels
r after three months of operation (water surface elevation equal to or greater than the
water surface elevation prior to installation of the System), at a minimum, the
following parameters shall be monitored: pH, BOD5, TSS, depth of effluent and DO in
the SAS and water use. The system owner will be responsible for certified laboratory
testing fees at competitive rates as well as costs associated with water usage
monitoring as required.Also see Section II, item 5 of the approval.
10. Monitoring shall continue for at least one year, when at the written request of the
System owner, the Department may reduce the monitoring and reporting
requirements. If after 120 days of operation, the System is in failure, the System shall
be removed in accordance with Section VI (7)of the approval.
11. By January 31 s`of each year for the previous year, the System owner shall submit to
the local approving authority all data collected in accordance with item 9, above,
including all Department Title 5,1/A O&M checklists and System technology checklists
completed during the previous calendar year by the System operator for each
inspection performed.
12. Prior to the issuance of a Certificate of Compliance for the System, the System owner
shall record and/or register in the appropriate Registry of Deeds and/or Land
Registration Office, a Notice disclosing both the existence of the alternative septic
system subject to this Approval on the property and the Department's approval of the
System. If the property subject to the Notice is unregistered land, the Notice shall be
marginally referenced on the owner's deed to the property. Within 30 days of
recording and/or registering the Notice, the System owner shall submit the following
to the Department and the local approving authority: (i)a certified Registry copy of
the Notice bearing the book and page/instrument number and/or document number;
and (ii) if the property is unregistered land, a Registry copy of the owner's deed to the
property, bearing the marginal reference.
a
have read and agree to the terms of this agreement.
Owner: Operator:
Date: Date:
A copy of this executed document.must be provided to the local
approving authority and Aero-Stream®, LLC.
2 of 2
Aero-Stream®,LLC
W300 N7706 Christine Lane Hartland,WI 53029
262.538.4000-Fax:262.538.4093
Web:www.aero-s-Fream.com .
S:\Aero-Stream\State Approval\MA Maintenance Agreement.doc a
DAV D J. BURN.IE MANAGEMENT, INC. Invoice
3 RY'S WAY
HARWICH,MA 02645 Date Invoice#
12/21/2010 1799
Ida
BILL TO t JOB ADDRESS
I-
STEPHEN DANIELL STEPHEN DANIELL
53 UNCLE WILLIES WAY 53 UNCLE WILLIES WAY
HYANNIS,MA 02601 HYANNIS,MA 02601
r
Technician Terms
DB
Item Quantity Description Rate Amount
SEPTIC REMEDIA... 1 SEPTIC REMEDIATION AS PER CONTRACT DATED 12/21/10.(NOTE: 4,000.00 4,000.00
INCORRECT UNIT INSTALLED.WILL RETURN TO INSTALL AS PER
CONTRACT.)
We appreciate your business. Than_k You!
Payments/Credits $4,000.00
E-mqil-db@dbumiemgmt.com
Web-capecodemergencyservices.com
508-432-0223 Toll Free 1-866-980-1440 Fax 508-430-1450 Balance Due $0.00
Barlistable
rTow ofY -ahistalble
Regulatory Services Department e;cac 1 I
Public Health Division m
"`') Mai Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean;CHO
Posted to door 17414ar, -f 2
•
3L i
March.7, 2012 Hand delivered*
Mr. &Mrs: Steven Daniell
.53 Uncle Willies Way
Hyannis, MA 02601 µ
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE; TTTLE 5
Hyannis MA last.ins ected on
The septic system located 53 Uncle Willies Way, Ilya s was p
2/07/2011, by David J. Burnie,a,certified septic inspector for the State of Massachusetts.:.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15,00) due.totthe following:
o Backup of sewage into facility or system component due to an overloaded or;
clogged SAS..
Static Liquid-Level in the distribution box above outlet invert due to an
overloaded or clogged SAS.
You are ordered,to repair or replace the septic system within thirty (30) days from the ^
date you receive this notification.' -
Failure to repair/replace the septic system within the deadline periodwill result in future
enforcement action.
PER ORDER OF BOARD OF HEALTH
T omas cKean, R S., CHO
Agent of the Board of Health pv; A '.:E f n, s
X
2 0 1 0
Q:\SEPTIC\Letters Septic Inspection'Failures-or.Future Eval\53 Uncle Willies hand.delivered.doc
f
oF1HE r, Town of Barnstable Barnstable
0
ft
Regulatory Services Department '°l� "'m'caC
> IIAEtNSCABLE,
r
MASS. Public Health Division
ATFJO)M 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508490-6304 Thomas A.McKean,CHO
2 01 2
Posted to door '>� -j^
March 7, 2012 Hand delivered
Mr. &Mrs. Steven Daniell
53 Uncle Willies Way
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 51
The septic system located 53 Uncle Willies Way,Hyannis MA was last inspected on
2/07/2011, by David J. Burnie, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system"Failed"under the guidelines
of 1995 TITLE 5 (310.CMR 15.00) due to the following:
•. Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
• Static Liquid Level in the distribution box above outlet invert due to an
: overloaded or clogged SAS.
You are ordered to repair or replace the septic system within thirty (M) days from the
date you receive this notification.
Failure to,repair/replace the septic system within the deadline period will result in future
enforcement action.
PER O THE BO OF HEALTH
Thom cKean, R.S., CHO
Agent of the Board-of Health
Q:\SEPTIC\L.etters Septic Inspection Failures or Future Eval\53 Uncle Willies hand delivered.doc
. i
I �
P�ofIHt Thy Own of Barnstable
r BOe`1 Barnstable
!' RILL STABLE, •► _Board of Health -MA. q
039. a�e� 200 Main Street,Hyannis MA 02601 11"niedcaeity
Ep MAt
Office: 508-8624644 2007
FAX: 508-790-6304
Wayne Miller,M.D..
Junichi Sawayanagi
Paul Canniff,D.M.D.
Mr. David J. Burnie
3 Perry's Way . January 28, 2011
Harwich , MA 02645
RE: 53 Uncle Willies Road, Hyannis/ Installation of Aero-S
Septic System Restoration Equipment tream Aerobic
Dear Mr. Burnie,
You are granted permission to install restoration equipment
Stream Aerobic Septic System Restoration Process)at 53 Uncle(Trade name: Aer
Hyannis, Massachusetts: Willies Road,,
1) The applicant must obtain a disposal works construction application process, the applicant shall submit the following:
(a). During the
as-built card, (b) diagram of the
the DEP approval letter proposed unit to be installed,( (c)� y o copy
of
dispos e
, (d) approved monitoring plan, (e) completed
works construction permit application form, and f payment
required permit application O P Y. ent of the
PP fee..
2) Monitoring and testing shall be performed in quarterly for
PH, BOD5,depth of effluent, and DO in the SAS during the first two years of operatic
and after that time period, the applicant may request a reduction upon
on
review of the testing information during a public Board meeting. Sample
analysis shall be conducted by an independent US, EPA or DEP approved
testing laboratory, or a DEP approved independent university laborato
Effluent samples shall be taken at a flowing discharge point. ry
3) The system owner shall also have the system monitored quarterly of ponding. q rterly for depth-
This permission is granted because the existing septic-s system J. Burnie, the applicant; has been.trained in the use of Solinim Len failure. Mr. David
Barologger equipment, according to Don Bur
cham of:Aero-stream LL gger and
{ C.
Smce'e1y your )
!,
Wajhe M ller,.M. t
Chairman`
Q:IWPFILESIIA Aeration 53 Uncle Willies.doc
201
arnstab e
Town of Barnstable
° Regulatory Services Department ''`� �
�. Public Health Division �
o a,
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
_ FAX: 508-790-6304 Thomas A.McKean,CHO
add . ':. "C*A..I
CERTIFIED MAIL#70D8 3230 0002.5178 2497
-. '` ' "fat
gg
¢,a
sE orrD oTrc � sS
March14,2011; �
' Mr& sStephe�nDarue
N
7 'S3tI1ric1e�W>tlhe
� Hyann sMA 02601 '
s+xy
} ORDER TO COMPLY�VI� NVIX0NNIENTAI C -- a " ' s .
K � '�, ST E E ` 3 ODE,TITLE 5 z P
fi Yro �r '" :n { r .a. Y3. W
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,^ - - IN
55
' rye�he s stem l xp y oca ence '�: yannis MAwas�last inspected on
�� 12/17%2010bDavidF4Bume ceztfedse thins e to� A� ,_ "
fo the State of
1Vlassachuse �s k k ` z
-Rill
��
The mspectlon of the se uc�s stems 'owedxthat� ers stem` "
Y
`Failed undefftl a delmes
9 , I y' (31C 15,0# 0)a ��the�followinof 195TTEN 0
• Backup of`sewa 'e.
p 4 g mto facility or systemxcomponent ue to;an�overIoa"ded
clogged SAS.'. , � k ,
x r yd —'e?yv ..ayl",.e, r
• Static liquid level'hi the distribut><on boxabove outlet><nvert ue to an f h
S A A � �� C
overloaded or clogged SAS F
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline,period will result in future
enforcement action.
OF THE.BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc
Y
4
t Town of Barnstable Barnstable
• ,�' �'o,� AaAmedcacity
.� Regulatory Services Department
sARNSTABM
Public Health Division
ArFD�.�p 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F:Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7008 3230 0002 5178 2497
SECOND NOTICE 1 '
March 14,2011,
Mr& Mrs Stephen Daniell
53 Uncle Willies Way, -
Hyannis,MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located 53 Uncle Willies Way, Hyannis MA was last inspected on .
12/17/2010,by David J. Burnie, a certified septic inspector for the State of
Massachusetts:
The inspection of the septic system showed that the system Failed under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Backup of sewage into facility or system component due to an overloaded or
clogged SAS
Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action,
OF THE BOARD OF HEALTH-
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\L.etters Septic Inspection Failures\I-I SAMPLE 60 Day Deadline:doc ;
I�0 ..
ti
i
� Postage $
Certified Fee j
ti
0 Return Receipt Fee [ g8tmark
M (Endorsement Required) l
Restricted Delivery Fee s/ y
r3 (Endorsement Required)
M Total Postage&Fees $ ✓s
m
CO Sent o
O .....................
--------------- ------ 1._
O Sfreet,AP.No.;
or PO Box No�i
crry,scare,zfP+a�r � f� �a 4d� ---
Certified Mail Provides:
o A mailing receipt -
o A unique identifier for your mailpiece
n A record of delivery kept'by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail@.
o Certified Mail is not available for any class of international mail.
is NO INSURANCE COV=RAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
a For an additional fee,a return Receipt may be requested to provide proof of
delivery.To obtain Returr Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the.
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
Town of Barnstable Barnstable
Regulatory Services Department Q AMmatcaM
* BARNSTABLE. s D '
9$A 63 Public Health Division m
jfD""p�a 200 Main Street, Hyannis-MA 02601 2007
t
Office:.508-862-4644 .. a Thomas F.Geiler,Director
FAX: 508-796-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7008 3230 0002 5178 2305
February 17,201 1p
Mr. Steven Daniell
53 Uncle Willies Way
Hyannis, MA 02601
{
ORDER TO COMPLY WITH-STATE ENVIRONMENTAL CODE, TITLE 5
The tseptic system located at'53 Uncle Willies Way;Hyannis MA was last inspected on
12/17/2010 by David J.Burnie, a certified septic inspector for the State of
Massachusetts.
The inspection of.the.septic system.showed that the system "Failed" under the guidelines
of 1995 TITLE 5.(3,10 CMR 15.00) due to the following:
• Backup of sewage into facility or system,component due to an overloaded or,
clogged.SAS.
• Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date`you receive this notification:.` a
Failure to repair/replace the septic system within the deadline period will-result in future
enforcement action.
ERIOF THErBOARD OF HEALTH'� 4.
Thomas-McKean;R�S.,`CHO ,C.
Agent-of the-Board of Health
Q:\kPTIC\Letters Septic lnspection Failures\1-1 SAMPLE 60 Day Deadline.doc .
w
7008 3230 0002 5178 2305 U.S.POSTAGE»PITNEYBOWES.
Town of Barnstable ��- �ANCM�
Public Health Division
RARN>A LE.g! 200 Main Street • �• ,)vNim ZIP 0260
$ 005.54' I
67q. 0 Y
p�ED Mn+" Hyannis,MA 02601 i 0001361475 FEB 1.7 2011. j
1 I
7008 3 230 0002 5178 2305
Mr. Steven Daniell
53 Uncle Willies Road
Hyannis, MA 02601
RETURN TO SENDER
UNCLAIMED
i3NAML1= "fO Ft�&�h9tma L7
y.. —.—.w�..r.a.,i+...:`}.�....�.*^..-!^ei. .. .r.-w----- �^.`. a-w,.-�.--v. '�ac-�.r.-.-+., ..-.r,-.-�•+-mow.--..�...,�^�c—�..,-=—.�..,c.�.,,��-,
SENDER: • •
COMPLETE • • DELIVERY
I {,
A Signature ' _ f
a Complete items 1,2,and 3.Also complete ❑Agent '
item 4 if Restricted Delivery Is desired. X ❑Addressee ' ,'
E Print your name and address on the reverse t 'x
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
a Attach this card to the back of the mailpiece,
or on the front if space permits. `M
D. Is delivery address different from Item 1? ❑Yes
I
❑No
1. Article Addressed to: If YES,enter delivery address below: f# + �
Mr. Steven Daniell 1^'J
53 Uncle Willies Road �j a
Hyannis, MA 02601 3. Service Type `
❑Certmed Mail ❑Express Mall
❑Registered ❑Return Receipt for Merchandise
r L ❑Insured Mail ❑C.O.D. 1 -
{ 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number C
(Transfer from service label) d d O' 3�3� ���
t PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
1
i .�- 1
1
� 1 \,
Town of Barnstable Barnstable
AFAmwicaCity
Regulatory Services Department P RARNSTAQLE,MASS. Public Health Division
MA+A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A:McKean,CHO
CERTIFIED MAIL# 7008 3230 0002 5178 2305
February 17,2011
Mr. Steven Daniell
53 Uncle Willies Way
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 53 Uncle Willies Way, Hyannis MA was last inspected on
12/17/2010,by David J. Burnie, a certified septic inspector for the State of
Massachusetts. _
The inspection of the septic system showed that the system "Failed" under the guidelines .
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or.system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution bok-above outlet invert due to an overloaded
or clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the.deadline period will result in future
enforcement action.
ER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\I-1 SAMPLE 60 Day Deadline.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD.
Property Address r "
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
City/Town 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 r
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David J. Burnie
use the return "
key. David J Burnie Management Inc
—� Company Name
3.Perry's Way
Company Address
Harwich MA 02645
City(rown • Y State Zip Code
508-432-0223............1-866-980-1440 ' S1386
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.ste
sewage disposal systems. I am a DEP approved system inspector pursuant to.Section 15340'of
Title 5(310 CMR 15.000).The system: -,
❑ Passes• ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority M
12-17-10 cn
M
Inspector's Signat mil` 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 flow the system will perform in the future under
the same or different conditions of use., lip/.11
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage sposal System•Page 1 of 17 t
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
City/Town 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:
1000 gallon septic tank , distribution box and'4 Hi cap Infiltrators. No plan on file at BHD Repair
permit dated 7-22-99
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 year's 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):
o
,
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wM 53 Uncle Willies RD
Property Address
. w
Steven Daniell y
Owner Owner's Name
information is
required for every Hyannis '" MA 02601 12-17-10
page. State Zip Code
Date of Inspection
Cityrrown
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):,
4 e
❑ 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,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts s
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell t
Owner Owner's Name
information is H annis MA` 02601
required for every y
page. State Zip Code 12-17-10
City(rown Date of Inspection.
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
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 aseptic 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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell '
Owner Owner's Name
- t
information is required for every Hyannis MA 02601 12-17-10 j
page. State Zip Code
Date of Inspection
City/Town
1
® ❑ 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
ElLiquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
B. Certification (cont.)
Yes No ,
E ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
❑ ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This. "
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system 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.
l5ins-09/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every Y 12-17-10 I
page. State Zip Code
Date of Inspection
City/Town
❑ ❑ 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.
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:
❑ E 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)]
t5ins-09/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
:Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owners Name }
information is H "'°MA 02601
Hyannis required for every Y 12-17-10
page. State Zip Code
Date of Inspection
Cityrrown
D. System Information
Residential Flow Conditions::
Number of bedrooms (design): 3. Number of bedrooms(actual). - 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
• -. - 4
D. System Information
h
Description:
1000 gallon Septic tank, 1 distribution box and 4 Hi cap infiltrators with 4' stone
t
Number of current residents: : 2
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? ®N Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): yes
Detail:
2010= 353gpd............ 2009=339gpd.....`...:'...2008=254gpd
Sump pump? f, r. ❑ Yes ® , No
Last date of occupancy: current
P Y Date
Commercial/Industrial Flow Conditions:
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 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owners Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
City/Town Date of Inspection
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:
D. System Information (cont.)
Last date of occupancy/user Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 3 times in the last month
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Truck calibration
Reason for pumping:
Type of System:' ,
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
J.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name -
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
Ci /Town Date of Inspection
ty ;•a.
❑ 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):,, ;� t
D. System Information (cont.),
te�installed (if known)and source of information:
Approximate age of:all components, da
Permit dated 7-22-99 t
Were sewage odors detected when arriving at the site? ❑ Yes ® No \
Building Sewer'(locate on site plan):
16"
` Depth below grade: ' feet
Material of construction:
El cast iron ®40 PVC, ,[] other(explain):
Distance from private water supply well or suction line: Town Water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All pipe and connections normal.
Septic Tank(locate on site plan):
Depth below grade feet -
t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owners Name
information is
required for every Hyannis MA 02601
10
page. State Zip Code Date of Inspection
Citylfown Date of pection
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Septic tank was overfull above inlet and outlet lines.
If tank is metal,. ist age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) _❑ Yes ❑ No
Dimensions: 1000 gallon per truck calibration
Sludge depth: 0
D. System Information (cont.)'!
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle0
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? System pumped.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank appears to be sound. no leaks. I
t5ins•09/08 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
�M 53 Uncle Willies RD
` Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every Y 12-17-10
page. State Zip Code
City/Town Date of Inspection.
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
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.):
x
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
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
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y
page. State Zip Code 12-17-10
Citylrown Date of Inspection
Design Flow: a, 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.):
t
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ® No
D: System Information.(cont.)
Distribution Box(if present must be opened) (locate on site plan):_
Depth.of liquid level above outlet invert. Overtull pumped dry
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.):
d box is usable for repair.
f
` Pump Chamber(locate on site plan):;
•Pumps in working order: y ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ,
Commonwealth of Massachusetts'
Title 5 Official. Inspection Form
Subsurface Sewage Disposal;System Form -Not-for Voluntary Assessments x
53 Uncle Willies RD
Property Address
Steven Daniell r,
Owner Owner's Name a ff _ n
information is }
required for every Hyannis MA 02601 12-17-10
page. ° State Zip Code ,
City/Town Date of Inspection `
Alarms in working order., ❑ Yes ❑ No -
Comments(note condition of pump chamber,'condition of pumps and appurtenances, etc.):
,
,
Soil Absorption Systein (SAS) (locate on,site plan, excavation not required): Y
If SAS not located,.ezplaimwhy: y 4.
Y ,
Located and viewed with a sewer camera,-'found,leaching overfull M • v
r �,
•
6 .
a n
a p
• u , f� a}N - L,
r ,
r
D. System Information.(cont.), y
r
Type:
leaching pits ti' _ number:
A.
lz' leaching,chambers number:
❑. leaching galleries. , number:
❑ leaching trenches;? number, length: 4
a ❑ leaching fields number,.dimensions:.
overflow cess pool` number:
❑, innovative/alternative system A
J• Type/name':of technology-a,
Comments(note condition of soil; signs of hydraulic failure, level of ponding, damp soil,=hdition of
vegetation, etc.): mm
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal'System•Page-13 of.17 ` {t
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
5 Property Address '
Steven Daniell
Owner Owner's Name
information is Hyannis 1 MA 02601
required for every y
1
page. State Zip Code Date of Inspection
:
Citylrown Date of pection
- y
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration a
Depth—top of liquid to inlet invert, _.
Depth of solids layer
Depth of scum layer
Dimensions of cesspool -
Materials of construction _
Indication of roundwater,inflow �`° , '
g El Yes`. ❑ No . •
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
t5ins-09/08 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
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y - 12-17-10
page. State Zip Code
Date of Inspection
City/Town ;
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation,
etc.): ;
leaching is overfull,backing,up into distribution box and Septic tank, back into the house
Y
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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
u v Title '5 official Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
M , 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's-Name
information is ;
required for every Hyannis MA , 02601 12-17-10
page. State Zip Code
Date of,inspection
Cityrrown
r
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water,
® .Check cellar
N
Shallow wells
Estimated depth to high ground water: 43
feet
Please indicate all methods used to determine the high ground water elevation:
}
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
H
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is
required for every Hyannis _ MA 02601 12-17-10
page. State Zip Code #
City/Town Date of Inspection
• 4
❑ 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) i
® Checked with local Board of Health -explain:
Form on file with BHD shows property at elevation 53'and ground water at elevation I'
10'=43' seperation
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
• •
You.must describe how you established the high ground water elevation:
Form on file at BHD property elevation is 53'ground water at 10'=43' seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
9 • r
Commonwealth of Massachusetts
Title 5 Official .Inspection Foam
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
53 Uncle Willies RD .
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis. MA 02601
required for every y 12-17-10
page. State Zip Code
Date of Inspection
Cityrrown
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,
use only the tab 1. Inspector:
Y Y
key to move our
cursor-do not David J. Burnie
use the return
key.
David J Burnie Management:lnc
Company Name
3 Perry's Way'
Company Address
Harwich MA 02645
City/Town State Zip Code
508-432-0223............1=866-980-1440_ S1386
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 15340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails 4
. a
❑ Needs Further Evaluation by the Local Approving Authority '
12-17-10 Cp
a,
Inspector's Sigr4t rl�-�' 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
' h 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)09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell.
Owner Owner's Name .
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
Date of Inspection
CitylTown
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:
1:000 gallon septic tank distribution box and 4.Hi cap Infiltrators. No plan on file atBHD Repair
permit dated 7 22-99
Bj '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 metalseptic tank will pass:inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name'
information is Hyannis MA 02601
required for every y 12-17-10
page. _ State Zip Code Date of Inspection
CitylTo wn
B. Certification
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):
❑ brokenpipe(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):
❑.t broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
i u
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,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
10 Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owners Name
information is Hyannis - MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
City/Town i
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
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-
El
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
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
l5ins 09108 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
53 Uncle Willies RD
SV Property Address
Steven Daniell
Owner Owner's Name-
information is 'Hyannis MA 02601
required for every12-17-10
page. State Zip Code Date of Inspection
city/Town
® 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 SASdor cesspool
El ❑ Liquid depth in cesspool is less than 6" below,invert or available volume is less
-than 1/2day flow
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:
El ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Oi ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
�.❑ '. z 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-
-.1 O,0000 pd.
The system fails: I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: Tabe 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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official-Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
❑ ❑ 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
El 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.
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
0 ❑ 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:
- Z 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
0. ® approximation of distance is unacceptable) [310 CMR 15.302(5)]
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonweaith of Massachusetts
Inspection Form
Tale 5 ®#ficial
m Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments
wM 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owners Name
information is Hyannis MA 02601
required for every Y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 +
D. System Information
Description:
1000 gallon Septic tank 1 distribution box and 4 Hi cap infiltrators with 4' stone
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ElYes ® No
Laundry system inspected?. Yes ❑ No
Seasonal use? ❑. Yes 0 .No
Water meter readings, if available last 2 ears usage d yes .
( Y 9 (gP ))� .
Detail:
201 0='353gpd..............2009=339gpd.............2008=254gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
P Y Date
Commercial/Industrial Flow Conditions:
t5ins•09/08 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
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:
D. System Information (cont.)
Last date of occupancy/use: Date
Ather(describe below):
General Information
Pumping Records: '
Soiarce'of information. - Pumped 3 times in the last month "
Was system pumped as part of.the inspection? ® Yes ❑ No
If yes, volume pumped: 1.000
gallons
How.was quantity pumped determined? Truck calibration
Reason for pumping:
.Type of System:
Septic tank,'-distribution box, soil`absorption system
❑ Single cesspool
t5ins-06/08 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
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityriown
El 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):
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Permit dated 7-22-99
Were sewage odors'detected when arriving at the site? ❑ `Yes ® No
Building Sewer(locate on site plan):
16"
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ` ❑ other(explain):
Distance from.private water supply well or suction line: Town Water
feet
Comments(on condition'of joints, venting, evidence of leakage, etc.):
All pipe and connections normal.
Septic Tank (locate on site plan):
12"
Depth below grade: feet
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
tl Commonwealth of.Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
Date of Inspection°
Cityrrown
E
Material of construction:
®concrete ❑ metal `''❑ fiberglass ❑ polyethylene ❑ other(explain)-
Septic tank was overfull above inlet and outlet lines. ;
If tank is metal,;list age: /
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ 'No
Dimensions: 1000 gallon per truck calibration
Sludge depth: 0
D. System Information (cont.) }
Septic Tank(cont.)
Distance from top of sludge to,bottom of outlet tee or baffle 0
Scum thickness 0
Distance from top of scum to top,of outlet tee or baffle 0
Distance from bottom,of scum to bottom of outlet tee or baffle 0
How were dimensions determined? System pumped.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural_integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank appears to be'sound. no leaks.I
t5ins•09/08 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
wM 53 Uncle Willies RD
Property Address.
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
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
D. System°I nformati6n'(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
t5ins•09/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal Syslem•Page 11 of 17
. -, r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every 12-17-10
page. State Zip Code Date of Inspection
-Cityrrown
Design Flow: gallons per day
Alarm present: ❑ Yes ElNo
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
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Overfull pumped dry
Comments(note if box is.level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage_ into.or out of boxi etc.).
d box is usable for repair.
Pump Chamber(locate.on.site plan):
Pumps in working order x ❑ Yes ❑ No
l5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form,-Not forVoluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
CityrFown
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:
Located and viewed with a sewer camera, found leaching overfull
#kw
P
D. System Information (cont.) k<
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative-system
TYpe/name of,technology: ,.
F
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
t5ins"09/08 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
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis, MA 02601
required for every 12-17-10
page. State Zip Code
City/Town � Date of Inspection
Cesspools (cesspool.must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depthw-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
D. System Information (cont.)
Comments note condition of soil .si ns of hydraulic failure level of ondin , condition of vegetation,
. 9 Y P 9 9
etc.):
Privy (locate on.site_plan):
Materials of construction:
Dimensions ?
Depth of solids
t5ins•09/08 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 53 Uncle Willies RD r
Property Address
Steven Daniell-
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
leaching is overfull backing up into distribution box and Septic tank, back into the house
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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
+ Commonwealth of Massachusetts
1. 4 Title 5 official: Inspection- Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 0260.1
required for every y 12-17-10
page. State Zip Code
Cityrrown Date of Inspection
3 ,
t
D. System Information (cont.)
Site Exam:
® Check Slope
ti ® Surface water
® Check cellar
Shallow wells
Estimated depth to high ground water: 43
feet
Please indicate all methods used to determine the high ground water elevation:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -;Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
CitylTown '
❑ 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:
Form on file with BHD shows property at elevation 53'and ground water at elevation
10''43'separation
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Form on file at BH:D property elevation,is 53'ground water at 10'=43' seperation. J
Before filing Inspection ection Report,please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
®,Inspection Summary: A, B, C, D, or, checked
Z' inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information- Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
,1 r
THE Tp��
Town of Barnstable Barnstable
PAgAm
°* Regulatory Services Department m'caN j
> BARNSTABLE,
639. ,�� Public Health Division
�ArFD"AP`p 200'Main Street,Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Posted to door
March 7, 2012 Hand delivered
Mr. & Mrs. Steven Daniell
53 Uncle Willies Way
Hyannis, MA 02601 `
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located 53 Uncle Willies Way, Hyannis MA was last inspected on
• 2/07/2011, by David J. Burnie, a certified septic inspector for the State of Massachusetts.
The inspection of the septic_system showed that the system"Failed" under the guidelines
of 1995 TITLE S (310 CMR 15.00)due Io the following:
• Backup of sewage into facility or system component due to an overloaded or .
clogged SAS.
Static Liquid Level in the distribution box above outlet invert due to an
overloaded or clogged SAS.
You are ordered to repair or replace the septic system within thirty (30) days from the
date you receive this notification.-
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
;PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Qi\SEPTIC\Letters Septic Inspection Failures or Future Eval\53 Uncle Willies hand delivered.doc '
V
Town of Barnstable Barnstable
MA
Regulatory Services Department 'Wea0 j
' IARNSfABLE,
039.
MASS.
° Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7008.3230 0002 5 178 2497
SECOND NOTICE
March 14,2011,
Mr& Mrs Stephen Daniell
53 Uncle Willies Way,
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
i
The septic system located 53 Uncle Willies Way, Hyannis MA.was last inspected on
12/17/2010,by.David J. Burnie, a certified septic inspector for the State of
Massachusetts.
t
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage.into facility or system component due to an overloaded or
clogged SAS
Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS
�l
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
�j
i
OF THE BOARD OF HEALTH
Thomas McKean,R.S., CHO
Agent of the Board of Health
�'. Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc N
.� t
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T
Barnstable
- °FjT° Town of Barnstable
Regulatory Services Department "caC`"
IIARNSTABLE, , r
MASS. A
039. ,gym
Public.Health Division
ArE°r"AY a 200 Main Street, Hyannis MA 02601 2007 m
office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#700832300602 5178'2305 -
February 17,2011
Mr. Steven Daniell
53 Uncle Willies Way
Hyannis, MA 0260.1
ORDER TO COMPLY WITH STATE ENVIRONMENTAL.CODE,TITLE S
The septic system located at 53 Uncle Willies Way, Hyannis MA was last inspected on
• 12/17/2010,by David J. Burnie, a certified septic inspector for the State of
Massachusetts.
The.inspection of the septic,system showed that the system "Failed" under the guidelines .
of 1995 TITLE 5 (310 CMR 15.00) due.to-the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS:
• Static-'liquid level in the distribution box above outlet'invert due to an overloaded
or clogged SAS
You are ordered to repair or replace the septic system within Sixty.(60) days from the
date you receive this notification. .
Failure to repair/replace the septic systemwithin the deadline-period will result in future
enforcement action.
ER OF THE BOARD OF•HEALTH
Thomas McKean,R.S.; CHO
.Agent of the-Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day'Deadline.doc
9
r DAV. D !. BURNIE MANAGEMENT;INC. Invoice
3 PEh RY'S WAY
HARWICH,MA 02645 Date Invoice#
12/21/2010 1799
BILL TO JOB ADDRESS
STEPHEN DANIELL STEPHEN DANIELL
53 UNCLE WILLIES WAY 53 UNCLE WILLIES WAY
HYANNIS,MA U601 , HYANMS,MA 02601.
Technician Terms
D13
Item Quantity, Description Rate Amount
SEPTIC REMEDIA... I .SEPTIC REMEDIATION AS PER CONTRACTI)ATED 12/21/10.(NOTE: 4,000.00 4,000.00
INCORRECT UNIT INSTALLED.WILL RETURN TO INSTALL AS'PER
CONTRACT.)
We appreciate your business'. Thank You!
Payments/Credits s-4,000.00
E-mail-db@dbumiemgmt.com
Web-capecodemergencyservices.com
508-432-0223 Toll Free 1-866-980-1440 Fax 508-430.1450 Balance Due. $0.00
THE FOLLOWING
RS/ARE THE BEST .
JMAGES. FROM POOR
Qid/1LIT3C ORIG.INAL (S)
Im / L
DATA
JOB INVOICE
� :Manager�erot, Inca
s efry's Way
/ga Harwich, MA 02645
/ 1-866- 80-1440 CUSTOMERS ORDER NO. DATE ORDERED +I
". ORDER TAKEN BY^t DATE PROMISED ❑ A.M. -
BILL TO -
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JOB NAME AND L CA I -
❑ DAY WORK -
DESCRIPTION OF WORK - '
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here acknowledge the satisfactory
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SIG RE' / - °`=
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TOTAL
CUSTOMER COPY f
J1931VID J. BURNIE MANAGEMENT, INC. Invoice
3 PERRY'S WAY
HARWICH,MA 02645 Date Invoice#
5/16/2011 2073
VP
BILL TO JOB ADDRESS
STEPHEN DANIELL STEPHEN DANIELL
53 UNCLE WILLIES WAY 53 UNCLE WILLIES WAY
HYANNIS,MA'02601 HYANNIS,MA 02601
Technician Terms
MB,JO' ' Due on receipt
Item Qty. Description Rate 'Amount
LABOR MB&JO CUT LINE DOWN AND INSTALLED A 3"CLEAN-OUT.NO CHARGE PER DB 0.00 0.00
PAYMENT GRAY BE MADE BY CHECK OR CREDIT CARD:
IF PAYING'BY:CREDIT CARD PLEASE-CALL THE OFFICE WITH YOUR NUMBER AND EXPIRATION DATE.
We appreciate your business.Thank You!
Payments/Credits $0.00
E-mail-db@dburniemgmt.com ,
Web-capecodemergencyservices.com
508-432-0223 Toll Free 1-866-980-1440 Fax 508-430-1450 BaI1IICe Due $0.00
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL(S)
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1866-9801440
I PHONE
- BR Date Invoice#
BILLTO - J�' / ✓ -MECHANIC- - - -
_ , 5/16/2011
2073
ADDRESS ='HELPER,-.
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JOB NAME AND LO ATION - ❑ CONTRACT -
EXTRA DDRESS
DESCRIPTION OF WORK
aPRICE AMOUNT'-
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AMOUNT TOTAL. - -
LABOR " 'MATERIALS
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hereby acknowledge the satisfacto °` 3-
Completion of 1he,abOVe described work -DATE COMPLETED T6T A L.
- •d
- SIGNATURE' -
i. - -- .•.�,I DE 1vMAIDE'BY CHECK OR CREDIT CARD.
_ �rc�'UYT CARD PLEASE CALL=THE OFFICE WITH YOUR NUMBER AND EXPIRATION DATE !
We appreciate your.business. Thank You!
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E-mail-db Pyffients/CreditsO.00
@dburniem gmt.com ,
Web=capecodemergencyservices.com
508-432-0223 Toll Free 1-866-980-1440 Fax 508 430 1450` ,Balance Due
$0.00
EXCERPT FROM BOARD OF HEALTH MEETING 1/11/2011:
1. Variance - Septic (New):
A. David Burnie, David J. Burnie Management, representing Steven
Daniell,:owner-- 53 Uncle Willie Road, Hyannis, Map/Parcel 292 -
311, Aero-Stream aerobicaeptic system restoration requested.
David Burnie was present and discussed the system with the Board. He agreed that
it is a similar type device as the Sludgehammer used at Fancy's Market, Osterville;
however, this one will be used as a residential solution. This is a three bedroom
house. This system is used on the leaching system but is not approved for general
use for the septic tank.
David Burnie gave.some general information on the system: it costs approximately
$3,500-4,000 for installation and a quarterly monitoring plan would cost - $325/year.
They would..recommend pumping it every 3-4 gears. After it is up and running, the
system would be thoroughly serviced every 3� or 4th year.
Mr. Burnie asked the Board if he would be allowed in the future to come to Health's
counter to obtain permission to use this system. The Board considered the staff
comments of wanting the Board to.review,new items as this and the Board
determined that it would need to come to the Board at this time.
There does not appear to be a'signed monitoring plan in hand yet. This is,"r"eeded'
for approval;,; Is the applicant agreeable to quarterly for three years, at which,time
they can come back to have it reviewed by the Board. The monitoring plan will be., • .
recorded with the Registry of.Deeds: _
Upon a motion duly made by Dr. Canniff,.seconded by Mr.. Sawayanagi, the Board'. _
voted to approve the system with the following conditions: a signed monitoring plan
with quarterly monitoring for the-first three,years, at which time the owner can come
back to the Board of review, there will be a recording at the County Registry of
Deeds showing the required monitoring plan, and a proper copy of the recording will
be brought tq the Public Health Division and upon completion of system: an as-built
will be submitted, along with a copy of the DEP approval letter. (Unanimously, voted
in favor.) i
;(
pL -
Commonwealth of Massachusetts
W Title. 5 Official Inspection dorm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name.
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
Cityrrown: Date of Inspection
Inspection results must be submitted on.this-form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms L General information
on the computer,
use only the tab 1. Inspector: �3
key to move your /
cursor-do not David J. Burnie
use the return
key.
David.J'Burnie Management Inc
r� Company Name
3 Perry's Way
Company Address i
Harwich MA .°02645
City/Town State " Zip Code
508-432---0223............1-866-980-1440 S1386
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 =
12-17-10 wr.
Inspector's Signat /lam Date
The system inspector shall submit a copy;of,this inspection report to the Approving Authority (Board
E 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.
15ins•09/08 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
. Commonwealth of Massachusetts
F = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityffown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D.or E/always complete all of Section D
A) System Passes:
have not found any information which indicates that any of the failure criteria described
-in 310 CMR 15.303 or in 31 O CMR 15.304 exist. Any failure criteria not evaluated are.
indicated below. _.
Comments:.
1000 gallon septic tank , dis box and 4 Hi cap Infiltrators. No plan on file at BHD Repair
permit dated 7-22-99
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
-_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
, 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
B. Certification (cont.) _
B) System Conditionally Passes'(cont.):
❑ Observation of sewage backup or breakout 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,
t5ins•09/08 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
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityfrown
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
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 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: .T
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
® El 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
R El than %day flow
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:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑' ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑. ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of-a cesspool or privy is within 50 feet of a private water,supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system.passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ 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) LargeSystems: 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every . Y 12-17-10
page. State Zip Code
Cityrrown Date of Inspection
❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply
the system is located ina 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.
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?
❑ E 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?
E. ❑ 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?
® El information
the facility owner(and occupants if different from owner) provided with
information on the maintenance of subsurface sewage disposal systems?
proper 9 P Y
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.
El ® 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)]
t5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6.of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every Y 12-17-10
page. State Zip Code Date of Inspection
CitylTown
D System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 +
D. System Information
Description:
1000 gallon Septic tank 1 distribution box and 4 Hi cap infiltrators with 4' stone
Number of current residents: 2
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 ears usage d yes
9 ( Y 9 (gP ))�
Detail:
2010= 353gpd.............2009=339gpd.............2008=254gpd
Sump pump? El
® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:-
l5ins-09/08 Title 5 Official Inspection Forth: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
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
:Cityf Town .
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:
D. System Information (cont.)
Last date of.occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 3 times in'the last month
Was system pumped as part of the inspection? ® Yes ❑ No
If yes,volume-pumped: 1000
gallons
How was quantity pumped determined?, Truck calibration
Reason for.pumping
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
l5ins-09108 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
,M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page State Zip Code Date of Inspection
City/Town
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 1/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other,(describe):
D. System Information (cont.)
Approximate age of all components date installed.(if known) and source of information:
Permit dated 7-22-99
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
16
Depth below grade: feet
Material of construction:
El cast iron Z. PVC ❑ other(explain):
Distance"from private water supply well or suction line: - Town Water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All pipe and connections normal.
Septic Tank(locate on site plan):
12„
Depth below grade: feet
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
Commonwealth of Massachusetts
Title 5 official - Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD "
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every Y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Septic tank was overfull above inlet and outlet lines.
If tank is metal,.list age: years
Is age confirmed by a-Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon per truck calibration
Sludge depth: 0
D. System Information (cont.)
(
Tank Septic Cont.
P
Distance from top of sludge to bottom of outlet tee or baffle 0
Scum thickness 0
Distance from top of scum to top of outlet tee or.6affle 0
Distance from bottom"of scum to bottom of outlet tee or baffle 0
How were dimensions determined? System pumped.
Comments(on pum ping.recommendations,.inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related.to outlet invert;evidence of leakage, etc.): .
Tank appears to be sound no leaks.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
x
Commonwealth of Massachusetts
W Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is MA 02601
required for every Hyannis 12-17-10
page. State Zip Code Date of Inspection
City/Town
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
4
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
D. System Information. (cont.)
Comments (on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity,
liquid levels as related to outlet inverti 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:
El concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
[Sins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of.17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form -
Subsurface Sewage Disposal System:Form -Not for Voluntary Assessments
°M 53 Uncle Willies RD #
Property Address _
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
City/Town
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
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):.
Depth of liquid level'above outlet invert ° Overfull pumped dry
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.):
d box is usable for repair.
Pump Chamber(locate on site plan)::
Pumps in working order: ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Ins ection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GM , 53 Uncle Willies RD - - -
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code Date of Inspection
Cityrrown
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:
Located and viewed with a sewer camera -found leaching overfull
{ D. System Information (cont.)
Type
- 9P❑
leachin its
number:
® leaching chambers number: 4
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.):
l•
l5ins-09/08 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
53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every Y 12-17-10
page. w. State Zip Code
Date of Inspection
Cityrrown
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
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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
y
Commonwealth,of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments
GM , 53 Uncle Willies RD - -
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y . 12-17-10
page. State Zip Code Date of Inspection
CityrFown
Comments(note condition of soil, signs`of hydraulic failure, level of ponding, condition of vegetation,
etc.):
leaching is overfull backing up into distribution box and Septic tank, back into the house
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D. System Information (cont.),y c
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`
E drawing attached separately
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
t
Y ,
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name
information is Hyannis MA 02601
required for every y 12-17-10
page. State Zip Code
Date of Inspection
City[Town
C
D. System Information (cont:)
Site Exam:
® Check Slope
Surface water
® Check cellar
Z Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage,Disposal System,Form Not for Voluntary Assessments
�M 53 Uncle Willies RD
Property Address
Steven Daniell
Owner Owner's Name _
information is
required for every Hyannis MA w 02601 12-17-10
page "• State Zip Code
Date of Inspection
Cityrfown .
�.
❑ . Obtained from systemPdesign pl ,a _on record
. z
If,checked, date of design plan reviewed:, pate
❑ Observed siie;,(abutting property/observation hole within 150 feet of,SAS) ,
®, F Checked with.local Board of Health -:explain:
Form'on file with°BHD shows property at elevation 53'..and ground water at elevation `
101=43'seperation
❑ Checked with local excavators installers-(attach,documentation) ,
❑ Accessed USES database=explain:' .
. ,
You must describe now you established the high'ground water elevation: r
established
Form on file at BHD property`elevation is-53'.ground water at 10'=43'seperation.
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Before filing this Inspection-Report, please see Report Completeness Checklist on next page.
wt ..
E: Report Cailrapieteness Checklist`
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® Inspection Summary: A; B, C,'D, or E checked
17
A.
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® Inspection Summary D(System Failure Criteria Applicable,to All Systems) completed
®, System informs#ion—,Estimated.depth to.high groundwater
®'Sketch of Sewage DisposalSystem either drawn�on page 15.or.attached in separate file
t5ins-09/08 .} Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION ,� SEWAGE#
VILLAGEASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS �
OWNER
PERMIT DATE: C011 NCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table h `Bottom of Leaching Facility Feet
Private Water Supply Well and Leachingacility(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
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TOWN OF BARNSTABLE Ly''
LOCATION E2 ILACA e W J&!J !�:' SEWAGE #
VILLAGE A/Vd4ZAO1 .9 ASSESSOR'S MAP & LOT9 L- f
INSTALLER'S NAME&PHONE NO. OL12/0 C�P . cc 'a i e
SEPTIC TANK CAPACITY l a O 0
LEACHING FACILITY: (type) ,roe 7""ir409&Ld, 2 (size) y
NO. OF BEDROOMS
BkM:DM OR OWNER
PERMUDATE: COMPL �'A O —
i�
Separation Distance Between the: ` ' 1��
Maximum Adjusted Groundwater:Tablett°o•tl Bottom of Leaching Facility Feet
n`' \,�
Private Water Supply Well andP.eactiing 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 o_Pqaching faci Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r,
Yes
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PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZippYication for Zi.5po!5a1 *paean Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System Tpkdividual Components
Location Address or Lot No. 3 �' ' (�?�� .A 5 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Lcl;�L— ^�t �"
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 21' Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flowyC'1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _ Type of S.A.S. t
Description of Soil
V T .
Nature of Repairs or Alterations(Answer when applicable) C�Q
"1) �- Ai� -E1lJ� yC,V� (��rrDGi'Tti 11L-C .'�"�U12C ( It��C�� .S��C/r,
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 h!�?en-igoed y t is
Signed Date
Application Approved by Date —Z Z
Application Disapproved for the following reasons
Permit No. Date Issued
��'..,.., �i•. ,�,� fig. .. _
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Fee • / '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:�rV/
Yes�
,_PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS L/
0(ppftcation for Mtq&6al *p,5tem Construction Permit
-- Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System jindividual Components
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`Location Address or Lot No. �J (�1,0` �� Owner's Name,Address and Tel.No.
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='r f Assessor's Map/Parcel'2cl
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
.�,.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow ��C1 gallons.
l' Plan Date Number of sheets Revision Date
Title
Size of Septic Tank nn C, Iq Type of S.A.S. G ��
Description of Soil
Nature of Repairs or Alterations(Answer.when applicable)
Le,_Vi� G o
�-,✓ S' l�
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 b e y s a t .
Signed Date — c[
Application Approved by D"at'e —Z Z
Application Disapproved for the following reasons s
1
Permit No. Date Issued
--------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,,,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(I/�
Abandoned( )by l
at ` has been constructed in accordance
with the provisions-.of Title 5 and the for Disposal qstern Construction Permit No. �F dated 7' Z�� - 27
Installer Designer r
The issuance of this permit shall not be construed as a guarantee that the s 11 function dde ned.
Date '" f1 l Inspectorec c
--—-- ——————————————————————————— — t ----- -
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
1wiquar *p5tem Conotruction Permit
Permission is hereby granted to Construct( )Repair( ) pgrade(L,.�<bandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be c pleted within three years of-the date of this p ermit.
Date: Approved by '
TOWN OF BARNSTABLE pp
LOCATION - l /An g Lem / SEWAGE it
VILLAGE��y(/�0,� �' ASSESSOR'S MAP & LOTg
INSTALLER'S NAME&PHONE NO. �- r.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) .,14,1l T !/7� — (size)
NO. OF BEDROOMS -
B R OR OWNER C5'4.Lf
PERMTTDATE: OMPLIANCE DATE:_ '"G'
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 o aching facie Feet
Furnished by
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NOTICE: This Form Is To Be Usid,For the Repair Of Failed
Septic Systems Only.-,v,
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
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L -� hereby certify that the application for disposal works
construction e p rmit signed.by-me dated -7--�-a' 1 � concerning the
property located at f,aO (,C�ca(� J I�� �� l5eets all of the
Mowing criteria:
The failed system is connected to'a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within'100 feet of the proposed septic'system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
ere are no vanances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
ma durum adjusted groundwater table elevation. (Adjust.the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
„ A),.Top.of Ground Surface Elevation(using GIS information) f
B)4 G.W.-Elevation +the High'G.W. Adjtistment 2 71__ 471 t
DIFFERENCE BETWEEN A and B
SIGNED : DAZE: 2 /
(Sketch proposed plan of system on back].
q:health folder.cert
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LO CA00N SEWAGE PERMIT NO.
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d`I VL A G E
INSTA LER'S ''NAME & ADDRESS
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��
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No.. .................... Fxs..... Vf..............
'iE COMMONWEALTH'OF MASSACHUSETTS
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BOAR®fa.,�4W
F F-I A TH
`........OF...... ... ... ...................................
Apptiration for DiDpaiial lUorkg Tantitrurtion Urrmit
Application is hereby made for a'Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: [ c , ' f I -
... 4
..............
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ion-Addp; r Lo N . .....
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............ r. -& ................ �..._. ?!s.!� 3111.E .... ----
wner ------•-------------------------Address
Installer Address
dType of Building Size Lot.................... .....Sq. feet
U
Dwelling—No. of Bedroo s___....tt.3—--_-•-..__._.•--.__--__--Expansion Attic ( ) Garbage Grinder 0
Other—Type of Build1q__.._. No. of persons____________________________ Showers ( ) — Cafeteria ( )
aOther fixtures ......................................................
W Design Flow...............55....................gallons per person per day. Total daily flow..............33-o.................gallons.
WSeptic Tank+Liquid capacity_I_COO_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------U.......... Diameter......19........ Depth below inlet_..._�.......... Total leaching area.Zb.b....sq. ft.
Z Other Distribution box ( ) Dosing�,) r
'~ Percolation Test Result Performed by..._`_.........-. _ _-__ r---------------------------------- Date..... r -..._._._.7 .....
as Test Pit No. 1___ .....minutes per inch Depth.of Te it.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' -------•--- ..................................
O Descrip0pri of Soil--------_0 --• .......? � = -----------------------•----
W ----------------
..••-•--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------------------------------------------------------------------•--------------------------------------------------------------•-------------------------------••--•••--........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LIT:..;; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenAssued by the board of health.
Sign . • •----- . ........... -•--•----It --- ------------------------
Date
Application Approved B _.._._. .
PP PP Y - --gd..-7 ------
- --------------•-•-•--••---•------•-----Date
Application Disapproved for the following reasons:................................... .... ._........__._
..............................---------•--------------------.....--------•---------.........----------------•-•-----•-•-•-•-••---•-. •------------------------------------------------------------•-••-
Date
Permit No......................................................... Issued-=;�•-gk. ---.
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.��
No-------------------------
Fps. !Z. .
K -;QiE COMMONWEALTH OF MASSACHUSETTS
J BOAR® f,3F H TI-I
OF.
Allp irtttion fur`Ili.spnlia1 1voths 00mlyiUrtion amit _.
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
ti System at
... .._ .......... ---•--•----------- -- --
................................ fit ...................... ....................... .._ .__.....
^
wner Address
W
�S .
Installer Address
Type of Building Size Lot............................Sq. Yet
aDwelling—No. of Bedroo s.__..-- _:._�-_•-•_•___.____•___-_______Expansion Attic ( ) Garbage Grinder
p-I Other—Type of Buildin WHAk tl: ______ No. of persons............................ Showers ( ) — Cafeteria ( )
a
� Other fixtures ---------------=-----=-----------------------------------------------------------------------------------••-•----------------._....----........------
.W Design Flow............... k.•.••. ._gallons per person per day. Total daily flow...............Z` r� ____---__-__gallons.
Septic 'Tank•17 Liquid capacity_I_' .gallons Length---------------- Width----------------- Diameter_____-_______-__ Depth................
Disposal,_Trench—No. .................... Width.....................Total Length.................... Total leaching area_____._.•__.__-_____sq. ft.
Seepage 'Pit No '_i_ ____________ Diameter._.___ _ ___-:,Depth:below inlet...... ..._..._. Total leaching area_. _ ....sq. ft. .
Z Other Distribution box ( ) Dosin ank
aPercolation Test Result Performed by. ._ J :_._-___ Date._._• "' .-!-1��-=-._...
Test Pit No. ,1._ ......minutes per inch Depth of�Te ___________________ Depth to ground.,water..................
f=, Test Pit No. 2....:::..:......minutes per inch Depth of Test Pit.................... Depth to- groundwater
.. ----••-•----••-------•-,-----
Co
O ]be-* p "on ofSoil----,••.4: : � ..•-- • .p - •-•-------,•--•-
!/ YY______________________________________________________il------.___-_______-----______-_-________________________ ....__..._...__________-__.__-_._._._-._..___-._..______.-_........•.-•_.
U Nature of Repairs or Alterations—Answer when applicable......_...........:�`___.-__._._.____.__________._________..___.__.___...._._--_____.______.
Agreement: :-
The undersigned agrees to install the aforedescribed Individual SewageFDisposal System in accordance with
the provisions of T IT= 5 of the State Sanitary Code-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,been issued by the bo4rd•of health.
signr' ------•-•----•• •--•-------...-••••------••---•-
Dat
Application Approved By.....- ----••- _._.r. :• . ; � ....... (1- ...-
Date
Application Disapproved for the following reasons:....................................-•-•------------•-•-----------••-•---•-•----•--•--•-- --•------•---------
.................•....•••---•-•-------•...•-•---•••-------......--••-•---•--------•----------•-•--.......--
Date
PermitNo......................................................... Issued ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... 6,
.................
Trrtifiratr oaf Toutplianrr
HATS IS4CEgIF1, That the u v' � evta e Disposal System constructed ( ) or Repaired ( )
by :. - ..........
*' lk install oe�
has been installed in accordance with the provisions of 'i'I;'. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction'Permit ��_____________ dated_.. '^� _ .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE > 3 Inspector .• ...........................
THZF
E COM;MONW AL•GH;mOF,•WASSACHUSETTS
� y� r
BOARD AF HEALTH
7
............0 .........OF........... a'' ...................................................... ;
No.....•.....�y... FEE..:4 ------.....
IV
rktrnrtinn rrntit
Per granted to ConstruNm, iss-ionjA,Wieby
, ) or R air ( n In iv u age pD s "Sal Syst
at No.. t
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as shown on the application for Disposal Works Construction Per •t _MM
d---�_-_s3�...._.__
Ith
_ - - .
DATE / ................................••---•---;
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
SOIL LOG k
'. �xti� lelCf4Wnrvir:�A[dai.artti...'iwv A 0^1kx
• f 1 8••;PEaSTQN6 LGA#A B_VIL4
BOX t'i • e °�. .. 40
01
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rs MIN .. 1000 4 (1 100.0— OAI,. v
2AL. {;o.• ' PRECAST OR , t.�0"
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SEPTIC S.1.�. 4� BLOCK t
TANK f• . SEEPAGE PIT D' 1
' 1, o u' a ♦ r,��t c �
- - r--• 20' 'MINIMUM o,e :e ''��Ql! . 14f _I 4 L, J . //e
I' a I ,.
FOUNDATION 1 /s" WASHED STWJE
E L E V AT I O N SKETCH �".`.- "'�'� +�' P 19116. *ATE�aJelou ?�rlwr��ac�i.
' SCA4E� I' 4' .
TEST QY+ u<'Ibjo rwo 7—T.V T ~
TOWN INSPECTOR: .nrt,_.4 ►�sf11wA�Er1�
SACKHOE OPERATOk = z � ..uE. +• r'" _
TEST MADE ON
owl
7'40
'� IF 03.
F pIts z 16 x *
3 Srt>12.
i , If as/0 4ts lop
M
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,Mood.
�\.. l+AWN/gyp ✓Oa,�~ �. • Lot' f
� per
Dah/
y' Alow0A7190;Avjri-too cw..�.JC � '.�
2)/Vv ,, 411l we.gl.•.ZW, 'g w &e r*s,i AV
♦ ci! WI;I 'AM G�
errs '• T��►!•O r 7 r, � �
ELEVATION SCHEDULE
PROPOSED SITE PLAN
I; LNV. AT F0UNDA'T10N - �9t.s
SSINAOS SYSTZU 0E810H
2. 1 NV. INTO SEPTIC TANK IN
3, 1 NV. OUT OF SEPTIC TANK 4JArU E 1-0 t1tCs- !-A-)A
4. INV, INTO DISTRIBUTION BOX - SCALE: 1-'= ?Op ;lUlt�ii �l 1910
5 ;1 NV OUT OF DISTRIBUTION BOX
6. INV INTQ. SEEPAGE PIT _ �
CAPE CUD SURVEY CONSULTANTS
ROUTE 132
7. BOTTOM OF PIT x• HYANNIS,MASS,
A ol'.visfON 0O11TON' BURY6Y CONSULTANTS,,I**.' -
8 BOTTOM OF . STONE LAYER ' �$• G